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Fall 2019 Newsletter

Cervicogenic Headaches: A Pain in the Neck

Sara Boughner, DPT, CPH

Nearly half of the global population has suffered from headaches at some point in their lives. While symptoms can range from a dull ache to an excruciating sharp pain, it is important to differentiate what the source of the headache truly is. The International Classification of Headache Disorders identifies 14 different types of headaches, with migraines, tension-type headaches, and cervicogenic headaches ranking as some of the most common. While physical therapy can treat the contributing factors of different kinds of headaches, it is most effective in alleviating the symptoms of cervicogenic headaches.1

Cervicogenic headaches are defined as a headache associated with and generally caused by neck pain, stiffness, and dysfunction in the cervical spine. They usually produce pain on one side of the head, and migrate to the front of the head from the posterior head and neck. Trigger points and occasional shoulder discomfort co-exist with cervicogenic headaches, which are aggravated by certain postures and painful neck positions. As one can imagine, these headaches are more prevalent in occupations that have sustained postures such as computer workers, hairdressers, and truck drivers. Cervicogenic headaches are more prevalent in women, and comprise of 15-20% of all headache sufferers.1

Upon physical examination, people experiencing cervicogenic headaches will show limited cervical range of motion, a sitting posture with the head forward and shoulders rounded, decreased neck and shoulder strength, and trigger points throughout the upper trapezius, sternocleidomastiod, and temporalis muscles. Resting in a posture with the head forward puts compression through the cervical spine, and shortens the neck and chest musculature making it more difficult to sit in a proper position.1

In line with the postural component of cervicogenic headaches, it is also seen that diminished strength of the shoulder contributes to this condition. The scapula will often rest down and away from the head, which will lengthen and weaken the levator, rhomboid, and trapezius muscles. Further investigation into this has shown that simple shoulder
strengthening exercises such as chest flies, lat pull-downs, and shoulder rows, especially when paired with specific neck strengthening and manual therapy, has been shown to significantly decrease cervicogenic headache symptoms. Some have even suggested that this shoulder weakness is one of the main causes of the headaches themselves.2

Diagram of tight and weak instances of the shoulder

Effective treatment of cervicogenic headaches requires a muli-factoral approach, and full assessment by a physical therapist or other medical professional is an important component of treatment. Specific neck and shoulder strengthening, manual therapy, and short-term use of modalities such as ice and TENS have been shown to be effective for
treating cervicogenic headaches.1,3 Because of this, cervicogenic headaches have a positive prognosis. They might be a pain in the neck, but the good news is that they don’t have to be.

1. Page P. CERVICOGENIC HEADACHES: AN EVIDENCELED APPROACH TO CLINICAL MANAGEMENT. International Journal of Sports Physical Therapy. 2011;6(3):254-266.
2. Huber J, Lisiński P, Polowczyk A. Reinvestigation of the dysfunction in neck and shoulder girdle muscles as the reason of cervicogenic headache among office workers. Disability and Rehabilitation. 2012;35(10):793-802. doi:10.3109/09638288.2012.709306.
3. Cervicogenic Headaches with Ken Niere. Pope D. https://www.clinicaledge.co/blog. https://wwwclinicaledgeco/blog. August 2012.

Muscle of the Month: Supraspinatus

Jesse Dupre, DPT

The supraspinatus is a relatively small muscle located at the top of the shoulder, and is one of 4 muscles that make up the rotator cuff. As a whole, the rotator cuff is very
important for shoulder stability and function. Dysfunction of the supraspinatus can contribute to diminished stability at the glenohumeral joint, shoulder pain, as well as
decreased shoulder mobility, and weakness when raising the arm to the side.

Diagram of the supraspinatusThe shoulder complex is made of a number of joints including the sternoclavicular joint, acromioclavicular joint, scapulothoracic joint and the glenohumeral joint. However, the glenohumeral joint is the one most commonly thought of when referring to the shoulder. The glenohumeral joint is classified as a ball and socket joint, where the glenoid fossa of the scapula functions as the socket, and the head of the humerus, or upper arm bone makes up the ball portion. The shoulder is capable of extensive motion in multiple planes, which is required to accomplish daily tasks. However, to accommodate such a wide range of motion, the glenoid fossa (socket) is relatively small and shallow, and the joint surfaces fit together more similarly to a golf ball on a golf tee. While this makes the shoulder incredibly mobile, it makes the glenohumeral inherently less stable, requiring greater contributions from ligamentous structures and the rotator cuff for stability. The supraspinatus is one important muscle to maintain dynamic stabilization of the joint, particularly when raising the arm upward.

The supraspinatus sits at the top of the shoulder, with most of the muscle over the scapula, and only a small portion of the muscle and the tendon crossing the glenohumeral joint. Exersice demonstration for the supraspinatusIt is attached at the supraspinous fossa of the scapula (shoulder blade), and at the greater tubercle of the humerus (bone of the upper arm). The supraspinatus has two primary functions. It assists with abduction of the shoulder (raising the arm laterally), particularly during the initial degrees of motion, and also assists in managing the shoulder joint, by helping to initiate the rolling motion at the joint and exerting a compressive force at the glenohumeral joint to prevent the head of the humerus from sliding upward excessively during motions where the arm is raised away from the body, particularly to the side. Supraspinatus pathologies or tears can be caused by trauma and external forces such as falling on an outstretched arm or over time as a result of repetitive overhead activities. These pathologies can impair the dynamic stability of the shoulder resulting in unrestricted upward glide of the humerus, which can contribute to impingement issues.

As the supraspinatus is part of the rotator cuff, it should be generally active during shoulder movements and exercise, however, it can be targeted with specific strengthening exercises. Full can shoulder scaption, where arms are raised from the side a 30-40 degree angle to the side and elevated to 90 degrees is a simple exercise to challenge the supraspinatus.

The supraspinatus does not work in isolation, and a number of other muscles must also act appropriately in order to decrease risk of shoulder pain or injury and for the shoulder to function well. The remaining rotator cuff muscles must work together to provide a compressive force to keep the humeral head from elevating, and help keep the head of the humerus from translating forward, and the periscapular muscles move the scapula to orient the glenohumeral joint to provide a stable foundation for the shoulder and decrease stress on the joint itself. If you have shoulder pain, a physical therapist may be able to help to correct strength imbalances and movement patterns to improve overall shoulder mechanics and function.

Foot Core

Sarah Menhennett, PT, DPT, SCS

There is a lot of buzz in the healthcare and fitness industries about the importance of having a “strong core” to prevent or treat low back pain and its importance for stability of the back, pelvis and hips. The local stabilizing muscles (core muscles) of the back and pelvis provide a stable base upon which the larger muscles can then initiate motion (bending forward and backward, twisted, etc).

What is “the foot core?”

It has been proposed that the same concept of “core stability” can be used in relation to the arch of the foot. Similar to the structure of the back and pelvis, there are local stabilizing muscles (intrinsic muscles) which work to stabilize the arch and larger muscles (extrinsic muscles) which move the foot and ankle and also add to the stability of the arch. 1

The “Foot Core System” is described in research as a group of three subsystems that the foot relies on for support and the ability to adapt to changing physical demands: neural (receptors in muscle/tendon, ligament, and skin), passive (bones, ligaments, plantar fascia), and active (intrinsic and extrinsic muscle). These subsystems must function appropriately together to provide adequate support of the foot during dynamic activities. Injury can cause a disruption in one or more of the subsystems.1 Here is a list of just a few issues that may have at least one disruption and will likely benefit from foot core training:

  • Achilles tendinopathy
  • Plantar fasciitis
  • Impaired balance
  • Ankle sprains
  • Post-operative foot and ankle surgery
  • During and after periods of non weight bearing
  • Individuals who respond well to arch support taping and/or orthotics

Although the passive support of arch taping or orthotics may be beneficial in the short-term following an injury in order to take stress off the healing tissues, training the foot core targets the active (muscular) subsystem of providing postural support to the foot. Additionally, allowing yourself to go barefoot periodically gives input
to the neural subsystem of the foot core system which is important for gait and balance.1 Foot and ankle flexibility and strength of the extrinsic muscles (calf and ankle) are also important components in the group of subsystems and often receive more attention than the intrinsic muscles. This is beginning to change as more research comes out highlighting the benefits of training the intrinsic foot muscles.

Contracted foot care image of foot exerciseOne great exercise to get started with foot core training is called “the short foot exercise”. This exercise isolates the “core contraction” of the foot. It is similar to an
abdominal “drawing in” exercise. It is started in the sitting position. Squeeze the arch of your foot, drawing the ball of your foot towards your heel (“shortening” the
foot). Hold for 10 seconds and repeat 10 times. Try to perform this 3 times per day.

Avoid contracting the muscles that cross your ankle and try not to dig your toes into the ground. Once you feel comfortable doing this exercise sitting, it can be progressed to being performed in standing and then on one leg and then with hopping and jumping activities to further challenge the dynamic control of the foot.

Image of foot with error circling the tendon flaringerror in exercise grasping with toes
A few other exercises that work both the intrinsic and extrinsic muscles of the foot are shown below: Towel scrunches (bunching up a towel using your toes), splaying of toes against resistance, and squeezing toes together. Perform these exercises with a 10 second hold, 10 times, 3 times per day.

Improving the strength of the foot core is important for those with foot, ankle, and lower extremity injuries in order increase and/or restore dynamic control of the foot. It may also be beneficial for healthy individuals to focus on foot cores strengthening for injury prevention of overuse injuries of the lower extremity related to poor foot control as well as athletic performance improvement.2 A small study of healthy males found that after 8 weeks of foot intrinsic strengthening, statistically significant improvements were observed for intrinsic foot flexor strength, vertical jump height, 1-legged long jump distance, 50-meter dash time. Foot arch length was also observed to have decreased, indicating improved muscular support of the arch.3 Whether you are recovering from an injury, wanting to prevent injury, or looking to gain an edge in your athletic endeavors, don’t forget about the importance of a strong foot core!

Three foot care exercise examples

McKeon, P. O., Hertel, J., Bramble, D., & Davis, I. (2015). The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med, 49(5), 290-290.

McKeon, P. O., & Fourchet, F. (2015). Freeing the foot: integrating the foot core system into rehabilitation for lower extremity injuries. Clinics in sports medicine, 34(2), 347-361.

Hashimoto, T., & Sakuraba, K. (2014). Strength training for the intrinsic flexor muscles of the foot: effects on muscle strength, the foot arch, and dynamic parameters before and after the training. Journal of physical therapy science, 26(3), 373-376.

Punch Card for Discounted Physical Therapy Offered

John Fiore, PT

Sapphire Physical Therapy is now offering a pre-paid punch card program for discounted physical therapy services. Due to the high deductible and out-of-pocket cost of health care and physical therapy specifically, we have created a pre-paid PT punch card program, offering PT visits at a discounted rate. Individuals may pre-pay for discounted PT visits. The pre-paid PT visits can be used between now and December 31, 2020 for any and all PT related services offered by Sapphire Physical Therapy.

The program follows the wellness model. Experience has shown that the high cost of PT services often results in individuals waiting too long prior to scheduling an appointment, resulting in a disruption of daily activities, fitness, and health. Early intervention is key in treating minor injuries so they do not become major injuries. Proper exercise
and training advice is important in reducing injury risk resulting from training errors.

The punch card program is perfect for individuals with high deductible health insurance plans who do not anticipate meeting their deductible. Health Savings Accounts and Flex Plan dollars may be used to pay for punch card PT visits. Please note that insurance will not be billed for the punch card program.

To learn more, see the flyer here or go to our website at http://www.sapphirept.com