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Our Role

SPINE AND SPORTS MEDICINE PROGRAMS

Doctors of chiropractic are usually known for spine care. This is true, but the field of chiropractic has grown and developed like all other avenues of health care and sports sciences. The doctors at the Soft Tissue Center have certainly provided care for acute and chronic low back pain and neck pain, as well as acute disc injuries with radiating pain in the upper and/or lower extremities. We have had the fortunate opportunity to work with elite spine surgeons at Cedars-Sinai Medical Center and Century City Hospital. We have had the opportunity to work in multi-disciplinary research and further develop post-operative care for microdiskectomies and fusions.

While we certainly do perform a significant amount of evaluation and treatment of the spine, we have an equally significant amount of experience in upper and lower extremity sports medicine and injuries. This is due to our training and deep involvement in the sports of track and field, hockey, soccer, baseball and weightlifting. It is sometimes easier for patients to view our role as two distinct "programs" when describing the work we provide: spine, and sports medicine. The strength and conditioning component and safety consultation for films for two other programs or services provided by this facility.

SPINE PROGRAM

Low back pain is one of the most common maladies known to the human race. Neck pain is very common as well. There are many reasons for low back pain and neck pain. Once spine pain occurs, injuries to the disc (which is located between the bony vertebrae) are the topic of conversations in almost any situation - work, home, social activities.

Often patients, and even some physicians, like to describe or quantify injuries to the discs of the spine as a measurement of the outcome of the patient. While the injury is sometimes so large and severe, it may provide some indication of functional outcome, it more often does not. This is the reason the theories of low back pain is included first.

Theories of Low Back Pain and Neck Pain

There are many sources of back pain. Far too often, other factors of pain are not taken into consideration. Patients may have an episode, or repeat episode of back pain and perhaps leg or arm pain. They often have an MRI and this scan reveals a disc protrusion (also called "bulge" or "herniation"). The disc protrusion is most often blamed for the patient's pain. However, the disc may have been protruded for many years before the episode of pain.

Disc pathology, or injuries, certainly can cause pain. However, a disc protrusion may not cause any pain at all. Since the MRI has had widespread use since the late 1980's, there were tens of thousands of reports from radiologists who either scanned the spine of a patient, or were scanning the abdomen or pelvis of a patient, and noticed a massive disc herniation. The radiologists questioned the patient about back and leg pain to only find out the patient had neither current pain nor any history of back pain and leg pain. This discovery lead to a change in the theories of spine related pain.

The older theory of disc protrusion related pain is a mechanical compression theory. This theory follows the idea that the disc was injured, and the injury produced a herniation which compressed the spinal nerve root as it passed by the disc. This compression would then cause back pain and pain, numbness, tingling, electrical sensations or any combination, radiating down the leg.

The problem with this theory is the tens of thousands of patients with massive disc herniations that have been seen on MRI on patients have never had symptoms don't seem to fit into the mechanical compression theory. Neurophysiologists came up with a new theory a few years ago. This theory is that of chemical inflammation instead of mechanical compression. This theory follows the idea that when the disc is acutely injured, it is inflamed and it releases chemical byproducts of inflammation. The inflamed disc material is near the nerve and inflames the nerve. Many surgeons refuted this concept by stating that the surgical procedures are designed to decompress that nerve and this is what obtains the desired results. The neurophysiologists countered by indicating surgical decompression didn't always work and when it did, the key point was the inflamed disc fragment was removed from the nerve, thus reducing chemical inflammation. Furthermore, and most importantly, there were tens of thousands of patients with compressed nerves from large disc herniations who never experienced pain. The neurophysiologists added that inflamed nerves probably tolerate compression less than normal, non-inflamed nerves.

So, today, significant back pain and leg pain is managed with powerful anti-inflammatory medication and conservative care, and more time is allowed for the nerve to calm before surgical intervention is considered. A common expression today in spine care is "We treat the patient, not the film". This indicates the changes in reliance upon the film for the diagnosis. The clinical exam is still the most important determining factor for the diagnosis.

Similar scenarios occur in neck pain. The major difference from low back pain is that the spinal cord stops in the upper lumbar spine, but it exists in the neck and mid back. This is a significant complicating factor. A large disc protrusion in the neck, or cervical spine, can compress the spinal cord. There are unique symptoms produced by spinal cord compression. There are other signs of cord compression that are silent. This makes an evaluation by a spine specialist necessary.

While the disc is capable of generating pain by itself, there are many other structures that can cause pain. Back pain can come from the joints in the spine that guide movement called the facet joints. The facet joints can become inflamed and they can become arthritic. Both of these conditions can cause pain. The connective tissue, known as fascia, can become too tight and painful. The muscles can also become too tight, or chronically inflamed and cause pain. The muscles can be too weak and cause low back pain but that is another topic. We often hear of tendinitis in other regions of the body, but it can occur in the spine as well and anyone who has experienced tendinitis knows it causes pain. Some patients have localized low back pain and a small branch off the spinal nerve root is inflamed and problematic. This small branch is known as the posterior, or dorsal, rami. This can cause back pain and dysfunction of the back muscles.

Role of the Soft Tissue Center in Spine Care

The staff at the Soft Tissue Center serves many roles in spine care. We often serve as the first stop for the patient, so the entire diagnostic work-up is completed. This includes a history and a thorough clinical examination. This may be followed up with x-rays, MRI, CT scans, spect scans, nerve studies (EMG and/or nerve conduction velocity studies) as indicated. The next step is to recommend either conservative care to decrease pain and improve function, or refer the patient for a combination of pain management and conservative care, or refer the patient for a neurosurgical consultation.

We are also sought for second and third opinions because our reputation is one for allowing enough time to hear the entire history and perform a thorough clinical examination. We can also review the previously performed tests and make our recommendations. Sometimes, we may concur that a case appears to be surgical and in other cases, we may recommend a brief trial of a combination of conservative approaches. The opposite may be true as well. For example, a patient may have had an injury to his/her neck. Conservative care may have been recommended by another facility. Our second or third opinion evaluation may reveal that the patient has signs of spinal cord compression, and we may recommend the patient to be evaluated immediately by a neurosurgeon (signs of spinal cord compression are often silent and are determined by the presence of pathological reflexes during an examination and correlating clinical symptoms).

The Soft Tissue Center often provides post-operative spine care to reduce pain, improve function and improve range of motion using soft tissue mobilization. Naturally, soft tissue mobilization is gently rendered in the early stages of post-operative rehabilitation.

Neurosurgeons often referred patients to the Soft Tissue Center for pain following a surgical procedure. The neurosurgeon would state that the surgical procedure was successful (i.e. the microdiskectomy resolved the patient's pain that was referred down their leg or arm, but the neck or back still hurt. The patients commonly viewed this as a failed surgery, although technically the procedure was successful. The surgical procedure decompressed the inflamed nerve root, but the soft tissue structures may still be too tight, inflamed, or fibrosed (have scar tissue). The muscles in the back or hip, or in the upper back and neck, may have these conditions and cause low back pain or neck pain. While the surgeon reduced the herniated disk, or bone spur, the soft tissue structures were not changed. Once the patient received soft tissue mobilization, the pain improved, range of motion improved, function improved and the patient then viewed the surgery as a good outcome. The neurosurgeons were happy also. This common scenario applies to microdiskectomies, microforaminotomies, one and two-level fusions with or without instrumentation, hemi-laminectomies, and laminectomies. Again, post-operative soft tissue mobilization is a common procedure.

SPORTS MEDICINE PROGRAM

Role of the Soft Tissue Center in Sports Medicine

The staff at the Soft Tissue Center serves many roles in sports medicine. As described in the section on spine care, we often serve as the first stop for the patient, so the entire diagnostic work-up is completed. This includes a history and a thorough clinical examination. This may be followed up with x-rays, MRI, CT scans, spect scans, nerve studies (EMG and/or nerve conduction velocity studies) as indicated. The next step is to recommend either conservative care, or refer the patient for a combination of pain management and conservative care, or refer the patient for a neurosurgical or orthopedic consultation.

The doctors of the Soft Tissue Center have all had post graduate sports medicine training, experience in the field, and are involved in research. We have had the fortunate opportunity to see a variety of extremity sports injuries.

We see many shoulder injuries at the Soft Tissue Center. We often see cases of rotator cuff tears, subacromial impingement, and due to the volume of throwing athletes we see, we have significant experience with diagnosis and management of cases with shoulder instability and labral tears (SLAP and Bankart lesions). Our success with shoulder injuries led to Dr. Horrigan writing the Sports Medicine Column for IRONMAN Magazine. A few years later, Dr. Horrigan was asked to write a lay rotator cuff book. This book is The 7-Minute Rotator Cuff Solution. The book was well received. It is temporarily out of print by may be available again in the winter of 2004 with a new publisher. Dr. Horrigan has also lectured for the last ten years on shoulder evaluation and treatment. A research article on MRI evaluation for rotator cuff exercise efficiency was performed by Dr. Horrigan and published in the journal Medicine and Science in Sports and Exercise in 1999.

We also see many knee injuries due to our experience and place in sports medicine. We often seen anterior cruciate ligament (ACL) sprains and tears and well as medial collateral ligament sprains and tears. Meniscus tears and articular cartilage damage are common and consequently, we rehabilitate these injuries often. These injuries often occur in football, hockey and soccer. There are many management options available to the patient, particularly with regard to the ACL injury. This is often overwhelming to the patient. We often help patients sort their way through the myriad of options so the patients can make a more informed decision.

The doctors at the Soft Tissue Center have had the fortunate opportunity to work with renowned orthopedic surgeons who specialize in foot and ankle injuries, so we often see acute and rehabilitating common inversion ankle sprains, "high ankle sprains", and post-operative foot and ankle patients.

When physicians work with various sports, they usually become quite familiar with the unique injury patterns in these sports. This is certainly the case with the Soft Tissue Center. We have worked with professional hockey players for fifteen years and Dr. Horrigan served as the Head Speed-Strength and Conditioning Coach for the Los Angeles Kings for three years and for the Long Beach Ice Dogs for seven years. Dr. Horrigan served as the Team Chiropractor for the Long Beach Ice for four years and this position was later assumed by Drs. Steven Tunnell and David Velasquez of the Soft Tissue Center. Dr. Chad Moreau works with the Ice Dogs as well. "Groin strains", or adductor strains, are common in hockey. We have seen, diagnosed and rehabilitated many cases of "groin" or adductor injuries in hockey, soccer and powerlifting. We have also seen 47 cases of tears of the abdominal muscles and established a rehab protocol after surgery for these injuries. This protocol was created with surgeon Craig Smith, MD who has performed over 100 of these repairs. A paper on this topic was presented at the American Orthopedic Society of Sports Medicine in July 2003 in San Diego by Drs. Feder, Smith, Shorr, Woodward and Horrigan.

Our significant work with track and field has allowed us to see countless hamstring strains, Achilles tendonitis and tears, groin strains and hip flexor strains. Dr. Horrigan lectures for the USA Track and Field Elite Hurdle Develop Program. These lectures have occurred at the Olympic Training Center in Chula Vista and at San Diego State University.

Dr. Horrigan serves on the Sports Medicine Committee for USA Weightlifting and has worked at national and international level for the last seven years. Michael P. Reed, DC, DACBSP, CSCS serves as the Chair of this Committee and asked Dr. Horrigan to join in 1998. The field work for Dr. Horrigan in USA Weightlifting has included being the Chief Medical Officer for Team USA at the 1999 Junior World Championships and 2003 World Championships. Drs. Tunnell, Velasquez and Moreau also worked at the 2002 Junior and School Age National Championships.

The significant amount of work our staff has performed in the field lead to the recognition of the sports performance problems that dehydration created in hockey. We designed a research project to help quantify this. Once the problem was quantified, we turned to
G. Douglas Andersen, DC, DACBSP, and Certified Clinical Nutritionist to devise a re-hydration protocol. Dr. Andersen served as the Team Nutritionist for the Long Beach Ice Dogs and later with the Los Angeles Kings. This protocol was very successful. The results of these two research projects can be found in the Abstracts section of this website. The protocol is also presented in Dr. Andersen's chapter in the book Strength, Conditioning and Injury Prevention for Hockey.

So, as one can see, our sports medicine experience is on all levels including field work, diagnosis and rehabilitation, research, publication, and instruction. If we are not able to help the patient, we will assist the patient in finding a health care provider who will be able to help.

Strength and Conditioning
Strength and conditioning has always been part of our practice, but its role has increased over the years. Strength and conditioning, and rehabilitation can be viewed as extensions of each other. Low-level strength and conditioning can be considered rehabilitation. There is no clear cut point where one ends and the other begins. We do know we are clearly in the realm of strength and conditioning and coaching when the athletes are at the highest level of sports performance.
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