Let us not forget the nerve

Lets not forget the nerve…..!
You do not need to be getting pins and needles, numbness, lancinating or burning pain for a diagnosis of neural problems to be made. In fact, within a good percentage of my clinical population, this is not reported as the primary feature of what turns out to be nerve dysfunction.
Amongst health care professionals the way in which the nerve moves is called neural dynamics, and thus if it is not working properly…adverse neural dynamics (AND). This diagnosis can easily be forgotten with the tendancy to fall back to more traditional structures like ligaments, muscles or cartilage being given the blame for your pain.
This is particularly pertinent in my mind due to the number of patients who seem to have gone through the mill, often having had multiple operations, only to establish that their pain is no better, and clearly had very little, if anything at all, to do with the structures that have been operated on. This can then become a very slippery slope, with often more surgery being undertaken to try and sort out a mechanical problem (often within a joint) that the MRI shows to be abnormal structure (lets not get started on MRI’s, the greatest gift and possibly one of the biggest curses every to grace modern medicine), when actually this is not the generator of pain. The problem remains unresolved with the patient often being left very frustrated, weak following the pain and rest post surgery, and not any better.
Testing the dynamics of the nerve is not complicated, but does require specific questioning and careful handling. It should be able to reproduce your symptoms, and should be modifiable with techniques to change the pull on the nerve. This might include taping, manually lifting the tissue that is above or below the restriction, or manipulation of any one of a number of interfaces through which the nerve passes.
Now I’m not saying this represents all problems, and in fact I would go so far as to say that this represents only a very few cases. But, it is a source of symptoms that should be identified early and effectively managed to save time, money and sometimes significant frustration and heartache.

The Biomechanical Injury Cliff

Forget the fiscal cliff….!
The spectrum of biomechanics…. who is most vulnerable to fall off the injury cliff?
Possibly more interesting for me as a clinician is that how is it that some people have been hanging on for such a long time with such poor mechanics without injury?
Should we intervene in a preventative fashion to address these suspected faults? Is the age-old question, and highlights the ever-growing debate about whether there is a role for screening to help injury prevention.
The reason I have been thinking about this problem is that over the last couple of months I have had come into my clinic a handful of serious runners. Guys (yes they were all men) who over a 3-4 year plus period, have been competing in marathons, ultra marathons, ironman’s etc, but who have all ended up seeing me as there world has coming crashing down around them (metaphorically speaking…in most cases at least) having picked up some sort of significant injury.
On all of these occasions these have been an ‘repetitive overload’ type injury, where there was not one single, large event, but a cumulative build up of discomfort, which on one run result in a tip from tolerable to unbearable. And, on every single occasion, I was genuinely shocked as to how poor these guys biomechanics where.
It made me therefore wonder several things….
1. If we had optimised their biomechanics from an early stage in their running career, could these injuries have been prevented?
2. Is it in fact just a problem with training load, as all these recreational athletes had been running with these mechanics for many years without problems?
3. And with that, if they had been surviving with these mechanics for so many years without problems, do we really know what optimal mechanics really are??
My thoughts are these, that without a doubt if we had optimised his biomechanics from an early stage in their running career the cumulative stress going down through the lower limb will have been reduced, and thus the risk of injury reduced…
That said however, mechanics are not the end of the story. I have seen people with wonderful mechanics still break down from injury as the training volume has been poorly tailored to them; their allotted recovery time, the quality of their recovery and their lifestyle away from the treadmill/road.
As with all things that we don’t fully understand, but believe we at least have a better understanding of than no understanding of at all, the problem is likely to be multifactoral…finding which factors are the key factors for you come down to the skill of being able to listen to your body, or the skill of somebody being able to listen to you and you being receptive to take this on board and act on it appropriately.