AILMENTS AND TREATMENTS
Treatments: what to expect
Click any of the headings below to learn more about the specific procedure.
Nearly every one of my patients receives some form of fascial manipulation as part of their treatment(s). Fascial manipulation is, simply stated, a scraping technique to create friction between two or more layers of fascia. Granted, the assessment process and treatment technique is more than just “scraping.”
With fascial manipulation, I generally expect my patients to experience significant improvements within 1-3 visits.
The purpose of fascial manipulation is to reduce densifications within the fascial matrix; these may occur be between the superficial and deep layers of fascia, around a tendon, around a joint capsule, or any other sub-type of body tissue in the broad category of fascia.
Unfortunately, fascial manipulation tends to be painful when the procedure is necessary. However, there is good news! First, treatments will only ever be performed to your tolerance. So, if you feel the treatment is too painful, I will ease up and treat to your pain tolerance, and the treatments will still be effective. Second, during treatment, if you ask me to stop for a break, the pain from treatment will immediately subside to 0/10 so you can take a breath and relax before reinitiating the treatment protocol.
If joint mobility and/or muscle flexibility are among your concerns, I will use one or more mobility exercises and/or stretch techniques that will certainly improve your range of motion.
Various techniques include:
- PAILs/RAILs (Progressive/Regressive Angular Isometric Loading)
- Post-facilitation stretching
- Post-isometric relaxation
- Controlled articular rotations (CARs)
Naturally, as a chiropractor, adjustments are among my most common services. Adjustment procedures include standard spinal adjustments (neck, midback, lower back), pelvic adjustments (sacroiliac joints), rib adjustments, and extremity adjustments (joints of the arms and legs).
Adjustments are valuable primarily for releasing joint restriction/fixation but may also aid to relieve pain, improve generalized stiffness in joints, relieve tension in muscles, and to improve overall mobility.
Beyond fascial manipulation and mobility exercises/stretches, other manual therapy and stretch techniques may be used to help reduce pain and tightness in muscles. Manual therapy techniques may include pressure release (or ischemic compression), simple massage techniques, or the use of the Hypervolt+ percussion massage tool.
Many physical ailments lead to inhibition* of particular muscles. For example, knee pain often leads to the inhibition of the vastus medialis muscle of the quadriceps—an important muscle for proper patellar (knee cap) tracking and general knee stability.
Target exercises may be used to retrain your nervous system on appropriately contracting a target muscle. This is often achieve by specific movement patterns and goading—or calling attention to the muscle by tapping or scraping it while you attempt to initiate a contraction.
*Inhibition of a muscle means your ability to elicit a muscle contraction has been reduced. This often occurs following an injury, a specific pain pattern, or overactivation of a specific muscle’s antagonist (e.g., lower trapezius inhibition from overactive upper trapezius).
The following information is for educational purposes only and is not intended to replace the advice of your doctor, even if you are an established patient of Art of Anatomy. Corey J. Csakai, DC and Art of Anatomy disclaim any liability for the decisions you make based on this information.
The information contained on this website does not establish, nor does it imply, doctor-patient relationship. Corey J. Csakai, DC and Art of Anatomy do not offer this information for diagnostic purposes. A diagnosis must not be assumed based on the information provided.
Fascial ailments include nearly all physical ailments; therefore, if something is wrong, there is a good chance your fascia is directly or indirectly involved. However, regardless of whether or not fascia is involved, below you will find a list of ailments I commonly treat including descriptions of each.
Click any of the headings below to learn more about the ailment.
By definition, chronic pain references a pain pattern that has lasted 6 weeks or longer. There are many causes of chronic pain; however, if you have physical pain and your experience is similar to the following (absent of illness or gross pathology), it is most likely an issue of fascial adhesion formation:
- You receive treatments such as massage, physical therapy, or chiropractic; you experience relief for a few days; but the pain pattern returns within a week
- You feel like you need to stretch, foam roll, or perform other types of self-care routinely or else your muscles will feel extremely tight and/or painful
- You stretch weekly or daily, and the stretches are uncomfortable or painful, but your range of motion does not seem to improve
- During massages or other treatments (including self-care), you feel like there are rocks or pebbles underneath your skin; the texture of the muscles seems “gritty” in nature
- You have seen multiple providers (medical, chiropractic, physical therapy, acupuncture, and/or specialists), but nobody has been able to identify a specific cause of your pain and/or tightness
- You have received a recommendation for surgery despite not having a true understanding of your pain
- You have “tried everything,” and you are feeling hopeless
Tendinopathy is the appropriate term for what most people—including many medical providers—mistakenly call “tendinitis.” Tendinopathies are often categorized as overuse injuries, and this is another, potentially misleading identifier.
Histological examination of tendinopathy shows disordered, haphazard healing with an absence of inflammatory cells, a poor healing response, noninflammatory intratendinous collagen degeneration, fiber disorientation and thinning, hypercellularity, scattered vascular ingrowth, and increased interfibrillar glycosaminoglycans.
Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87:187-202.
If you experience pain in a tendon during movements—in particular, movements against resistance—then you may be experiencing a tendinopathy. Other hallmark signs of a tendinopathy include pain that becomes less intense after a warm-up or during physical activity, pain that worsens following periods of rest, and significant pain when the tendon is pulling against resistance.
Common tendinopathies include:
- Tennis elbow (lateral epicodylosis): outer portion of the elbow
- Golfer’s elbow (medial epicondylosis): inner portion of the elbow
- Proximal or distal biceps brachii: front of the shoulder or in the elbow crease
- Hip flexors (iliopsoas and/or rectus femoris): front of the hip
- Proximal or distal hamstrings: gluteal region or back of the knee
- Achilles tendinopathy: behind the heel
- Patellar tendinopathy: just below the knee cap
Nerve impingements are when a nerve or bundle of nerves is being compressed. There are many different causes of nerve impingement, and a lot of them are not caused by issues with fascia.
One example of a non-fascial nerve impingement is one that occurs due to bony stenosis (narrowing); this is particularly dangerous in the spine when the spinal cord or nerve roots become compressed by the crowding of bone growth. Other non-fascial nerve impingements include inflammation and external compression.
However, many nerve impingements, particularly those in the arms and legs (extremities), may be caused—directly or indirectly—by fascial ailments. Nerve impingements will most often cause numbness, tingling, or weakness in a particular area of the body. Other symptoms of nerve impingement may include altered sensitivity, either increased or decreased, compared to normal touch sensation.
Common nerve impingements that may be caused or exacerbated by fascial ailments include:
- Carpal tunnel syndrome: symptoms on the palm side of the thumb, index, and middle finger
- Cubital tunnel syndrome: symptoms in the pinky finger, ring finger, and the pinky side of the entire hand
- Radial nerve impingement: symptoms in the back of the upper arm, top of the forearm, or the back of the hand (thumb, index, and middle finger, only)
- Brachial plexus impingement: symptoms may present anywhere in the entire upper extremity in non-specific patterns
- Sciatica: symptoms down the back of the thigh, back and outer portion of the lower leg and foot
- Common peroneal nerve impingement: symptoms down the outer portion of the lower leg and foot
- Tarsal tunnel syndrome or posterior tibial nerve impingement: symptoms on the bottom of the foot in the big toe, 2nd and 3rd toes
Plantar fasciitis is another ailment that is inappropriately named. The suffix -itis implies an inflammatory process, and much like tendinopathy, inflammation is not significant and therefore not a cause of the pain for this condition.
Instead, plantar fasciitis is the presence of adhesion formation within the fascial matrix of the plantar fascia—a thick band of connective tissue that supports the undersurface of your foot. A simple way to think of adhesions within fascia is to visualize VELCRO® strips. While this is not an entirely accurate representation, I use this example to help people visualize the fibers of fascia becoming tight and immobile (“stuck” to one another) beneath your skin.
The hallmark symptom of plantar fasciitis is an intense, sharp pain on the inner half of the bottom of the heel. This pain will most often be significantly worse in the morning when you first try to walk after getting out of bed, and it is common to experience some relief as you continue to walk and move. This condition is often debilitating and can result in the inability to walk.
Please note: surgery is usually not an appropriate treatment for this condition! In fact, surgery can make plantar fasciitis worse and/or permanent! Since the ailment is categorized by fascial adhesions, it can also be categorized as transient; in other words, it can easily be treated to resolution! Like muscles, fascia is malleable and can be manipulated to create change.
However, if you get surgery, there will be scar tissue in the area of the surgery, and scar tissue is permanent. It cannot be broken down or released. Therefore, if you have scar tissue causing a plantar fasciitis-type pain pattern, you may not be able to resolve this issue.
There are many different types of headaches. One of the most common types of headaches are tension-type headaches caused by myofascial trigger points. In other words, tension in the muscles and/or fascia of the head, neck, and upper back will refer pain into different regions of the head. These are considered secondary headaches because the pain is not truly in the head.
Tension-type headaches most often present as a dull, diffuse aching sensation. The pain is usually poorly localized and may feel like tightness in different areas of the head. You are unlikely to experience significant relief from a tension-type headache if you take NSAIDs (e.g., ibuprofen [Advil], naproxen [Aleve], or other over the counter anti-inflammatory medications).
Common tension-type headache patterns include:
- Suboccipital muscles: pain in the back of the head at the base of the skull or around the eyes (described as orbital headaches); this pain will only present on the same side as the trigger point(s)
- Upper trapezius: pain tracing up the side of the head and around the ear; this pain will only present on the same side as the trigger point(s)
- Sternocleidomastoid: pain in front of or behind the ear or along the forehead; the ear pain will only present on the same side as the trigger point(s), but the forehead pain may present on either side
The iliotibial band (IT-band) is a long band of fascia on the outer portion of your thigh. This structure is primarily responsible for lateral stability of the knee. However, since the IT-band is fascia, it is prone to developing adhesions. When the IT-band develops adhesions, it becomes tense, creating a significant increase in tension on the entire outer portion of your thigh.
When this occurs, the tension will increase the activation of the outer portion of the quadriceps muscle group—a muscle called the vastus lateralis. When the vastus lateralis becomes overactive, it pulls harder than the muscle on the inner portion of your thigh—the vastus medialis.
Ultimately, the increase in tension on the outer half in comparison to the inner half will pull the knee cap slightly off track, resulting in a condition called patellar-femoral disorder. The knee cap slides slightly to the side and may feel like it is grinding against the bone underneath.
Procedures such as stretching, foam rolling, generic massage, and percussion massage will not be useful in providing a lasting release of tension in the IT-band. Instead, as mentioned earlier, you may experience transient relief or pain and/or tightness which returns within a week.
Referring back to the Fascia Research Congress’s definition, fascia “incorporates elements such as adipose tissue…” I have previously described the presence of adhesion formation within the matrix of various types of fascia. The adhesion formation will cause increased tension in the surrounding tissue; when adhesions occur in the fascia containing adipose (fat) tissue, it will begin to squeeze the fat cells. The result of this tension around adipose tissue is a dimpled appearance in the skin described as cellulite.
Cellulite is not specific to your fitness level or body composition; however, it tends to be less likely to develop cellulite if you are physically active because fascial adhesion formation is less likely when bodily movements are balanced. Fortunately, like the other conditions that occur due to fascial adhesions, cellulite can often be treated to resolution.
*Note: results may vary, but in past experience, the dimpled appearance of cellulite was reduced and often eliminated with fascial manipulation treatments.
Muscular imbalance may come in various forms. Common examples include a strength discrepancy between each side of your body (e.g., one arm feels significantly stronger than the other) or an inappropriate strength ratio between agonist and antagonist (e.g., quadriceps-to-hamstring strength ration being significantly different than ~3:2).
In any case, muscular imbalances are often easily treated with a combination of fascial manipulation, post facilitation stretching, and target activation and strengthening exercises.
Restricted mobility will be caused by one or both of two major factors: lack of joint mobility or lack of muscle flexibility.
In the case of lack of joint mobility, the joint capsule is restricting movement. This issue will most often present with a feeling of intense tightness, pinching, or pain that is deep in the area of the specific joint. At the same time, the lack of mobility will not likely allow any of the surrounding muscles to reach a full stretch.
For lack of muscle flexibility, there are actually two possible causes. One issue may be that the muscle, itself, is short. However, this problem is extremely uncommon. The more likely issue is a muscle that is chronically hypertonic.* In this case, the muscle is constantly in a low-grade contraction, and so you are not reaching the muscle’s full length. Instead, you are fighting against a contracting muscle.
Basic, static stretching will never release the tension or improve the muscle’s flexibility if the issue is chronic hypertonicity. Instead, you must decrease the activation to the target muscle. The best ways to achieve this goal are through post facilitation stretching or PAILs/RAILs.
*The word “tone” is generally in reference to a muscle’s tension in a relaxed state—also called resting tone. At rest, a muscle should feel soft, and this tone should maintain throughout early stages of static stretching.
Increased tone (“hypertonic”) indicates there is neural activity triggering the muscle to contract at a low level. Ultimately, performing a static stretch on a hypertonic muscle is the equivalent of an isometric exercise (e.g., an abdominal plank) which will not improve the flexibility or length of the target muscle.
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