I miss your skin

I miss your skin

the planes of shoulder blades
layers of muscle overlying them
the trapezius sweeping up to the base of the skull
and down to the tenth vertebrae
like a wing pointed inwards
on your back
and attached to bones

more and more in clinic
I pull out Netter’s beautiful drawings
and show people the bones
and that the bones are not just floating
in a sea of muscle and organs
every bone is attached to muscles
to tendons to ligaments
together in an elaborate
beautiful
working system
and if one muscle is torn too loose
or tightens to protect itself
and heals scarred calcified
too short
it pulls on the other muscles
and tendons and bones

I miss your skin
your muscle
your tendons
your ligaments
your bones

and all the rest

 

I took the photograph in the boatyard in 2016. Sometimes I dream I have feathers….

 

 

Work place

Mostly I post photographs from outdoors, but this is clinic Friday afternoon. Mordecai took off her feather boa, wig and headdress and came into the exam room to add to a visual discussion about the sacroiliac joints. Mordecai is a plastic skeleton and her sacroiliac joints are attached incorrectly but conveniently for the sellers. After all, her bones don’t have the weight of a real skeleton nor does she have tendons or muscles or skin to connect everything. She is sitting beside my Netter Atlas of Human Anatomy, which I use in clinic every day. To show the knee ligaments and menisci, to show the back muscles, to show the connections of the psoas muscle….

Many thanks to Dr. Netter’s brilliant paintings and also to Mordecai for their help!

 

Does back pain mean a disc?

Does back pain mean a disc?

Does sciatica, pain down the sciatic nerve, all the way down the leg, mean a lumbar disc is out of position and you need back surgery?

Ninety nine times out of one hundred: No.

No? What? Really? Doesn’t back pain and sciatic pain mean a disc is pressing on the nerve?

Nope.

Sciatica means that the nerve is annoyed. It is sending pain signals. It can be irritated and inflamed anywhere along the entire path of the nerve. When the nerve is inflammed or there is surrounding inflamation, the nerve sends pain signals.

But… if it is not a disc, WHAT IS IT?

Muscles that are injured, inflamed, irritated, contracted or torn, that in turn put pressure on or inflame the nerve.

The sciatic nerve is made up of multiple nerve roots coming from the spinal cord: L3, L4, L5, S1, S2, S3. And then variants. The nerve roots bundle together and then dive through a group of muscles and go down the back of the leg: deep in the muscles. Why deep? To protect this very big, very important, bundle of nerves. Branches veer off and innervate muscles and bone and tendon and fascia, all the way down to the toes. There is not a spinal column in the leg, to protect this nerve.

It dives in between the superior gemellus and the piriformes muscle, deep in the buttock. Under the gluteus maximus and the gluteus minimus. Then it goes down the leg, under the semitendonosus muscle and the biceps femoris muuscle, the big hamstrings.

Now, let’s go back up to the low back. Why does it hurt? With or without sciatica? There are six layers of muscles in the back, all way smaller than those hamstrings. The top is the latissimus dorsi, down 5 more layers to the small longus and brevis rotares muscles, which connect each vertebral bone and allow subtle and complex movements of the spine.

What happens when a muscle is torn or injured? People look blank in clinic when I ask. I say, “Think of a piece of steak, what happens when you cut it?” They still look blank. “It BLEEDS, right?” When a muscle is torn or injured and bleeds, it and the surrounding muscles cramp up as much as they can, to try to prevent further bleeding and tearing. If it is an extremity, ace wrap, elevate and ice, as soon as possible, to slow the swelling and bleeding and pain. If it is the lower back muscles, ice as soon as possible and applying pressure won’t hurt. No heat for 48 hours since muscle bleeding and swelling and inflammation usually peak at 48 hours. After 48 hours apply heat, then gently stretch, then ice after stretching.

Think of the muscle fibers as torn. They take about 6 to 8 weeks to fully heal. You want to stretch them and rehabilitate them without tearing them in that 6-8 weeks. You want every muscle to be fully functional, to be the right length, to not heal shortened or scarred. Get those fibers working again…

….or….

But doctor, my back has been hurting for FIVE YEARS!

Then it will take longer than 6 to 8 weeks to rehabilitate, retrain the muscles, gently break down the scar tissue, get it all functioning. Your muscles are doing their best. They told you they were hurt and you need to listen to them.

Covering it up with ibuprofen or alcohol or any number of substances or trying to ignore what your muscles are trying to tell you is a bit counter productive, don’t you think? Pain is information. An advil can help with the pain, but it does NOT fix the problem. “Drug me so that I can go on ignoring it.”…. uh, no. That is not ethical and it also doesn’t work.

And just think, if those back muscles continue tighter and tighter… they are constricting and pulling on the spinal bones.  They pull on those bones and then a disc might be thinned or crushed and might protrude and then press on a nerve. And then for surgery, what do they do to get to the disc? Cut through the six layers of muscle….

Armour Suit IV: Walk like a toddler

At each massage, one every two weeks, I have locked my hips back up in the Armour suit. This is really annoying.

My massage person says he wants to be able to lie face down like a baby: head, arms and legs all lifted and playing. That is core strength. Babies can do that… why can’t we? He says that when he does play therapy with kids, by a certain age they lose that. He picks them up and flies them around lying on his arms: by age 4 or 5, they fold up. They have lost touch with that core.

I think about that.

During a massage a few months ago he pokes my lower belly. “Tilt your hips using your abdominal muscles.” Feels weird, but I do. “You aren’t engaging your core.” I find it really annoying to have to relearn how to walk.

Engaging my core. Little children who have just learned to walk do lead with their bellies. And they can still lie on the floor on their bellies, all limbs up.

I am trying to picture an adult who walks with their belly. Who? The Buddha’s belly comes to mind. But I can’t see him walking. Who? Toshiro Mifune: the old samurai movies. He and the others walk like small children: from their core, from their bellies.

I try it for two weeks. I flatten the arch of my lower back by using my abdominal muscles, not my gluteus maximus. I walk with my feet apart a bit, my belly leading. I am trying not to walk with my toes gripping the ground. I walk with toes up. He says I have walked with my toes gripping the ground for years, and that is the only place that I have early arthritis.

It feels a bit silly to walk like a samurai. When I do it right, I can feel that engaged core and my legs and hips feel looser. It is not elegant, not a catwalk uptight shake your ass walk. It is more of a loose free walk, like a toddler, like a buddha. I don’t care. I have to concentrate to keep my abdominal muscles flattening the arch of my back, and so I walk slower.

After two weeks I am back: it’s worked. Partially. My hips are LESS locked. The metatarsal phalangeal joints, the big toes, are less sore then they’ve been for years. And I can feel that abdominal core.

Skiing I try to do the same thing. Engage the abdomen and keep it engaged, and ski with my toes up. I ski slowly and with great swooping turns, letting the skis do the work. Rentals. They give me 158s the first day, I talk them into 165s the second day and then I am on 172s. Finally feels stable. I am getting used to that core feeling. I quit when I get too tired, going in before my kids.

Walk like a toddler, walk like a samurai, walk with core engaged.

First published on everything2.com January 7, 2016. I needed the right picture: this is my sister and me about a month before she died of breast cancer. I miss her so.

Armour Suit III

My trial run for this vacation is swimming 400 yards. The swim is slow but fine. However, at 4:30 am I start having vertigo and throwing up. Have to cancel clinic. Lasts about 4 hours. Not reassuring for our Christmas plans.

My daughter has her wisdom teeth out on Monday before Christmas, so is instructed to not exercise heavily for five days. I got dry sockets and was sick as snot in college, but mine were much more impacted. She does fine, stops the hydrocodone in 24 hours, and drops to a 200mg ibuprofen three times a day by Christmas. On with the ski plans!

We head for a family resort on the east side. Up to to slopes on a hotel ski bus the first day, renting skis. For the first time ever, my goal is to ski gently. I have been skiing since age 9, but have not skied in five years and had two major bouts with strep A that affect my muscles. The second time my fast twitch muscles didn’t work for ten months. The first goal was to survive and the second is will I get my muscles back?

I rent downhill skis. Last time I skied telemark, but they don’t have any to rent, and anyhow, tele is harder. In college I had 190cm dead straight Heads for downhill, so now they rent me 163cm skis. We ride the lift up. 20 degrees at the top, an inch of new snow on groomed slopes and gorgeous. And… I can ski.

I am trying NOT to engage the armour suit. My massage person thinks that’s what made me sick swimming, reengaging it and just trashing my muscles. He’s right, I think. I just swam the way I always have, but slowly. My goal down the hill is NOT to fall into old patterns. I ski gently, let the skis do much of the work, carving swoopy turns. Every so often I get quickly and feel the suit kicking in and I back off. I drag my right pole for balance when I am tired.

My daughter asks for pointers on our third or fourth run. She has not skied for five years either. She is doing the work and I show her how to finish a turn using the curve of the ski. Finishing the turn lets her slow down, so she gets the swoopy feel in the turn but doesn’t lose control. On the lift we watch people. Nearly everyone drops their hands. Try turning your lower body with your arms dropped behind. Doesn’t work. Hands and shoulders down the hill and let the lower body do the turning….

I can ski! I ski with my toes lifted, not curled and gripping the ground. It changes my balance and I have to pay attention not to engage the suit. By 11 I want food and on the chair at 2 I am on my last run: I can feel the cold through my coat. We have a few more days, save energy. Also my right shin is informing me that I’ve bruised the crap out of it…

And the next day! Bruised shin, but more skiing, still gently. Now I have hope that I will get muscles back! Hooray for hope! Hooray for skiing toes up! Hooray for skiing without armour!

Armour Suit II

Yesterday I had the massage that I have once every two weeks.

We talk first about muscles and illness and emotions. He is thinking that if we forget how to use certain muscles and put them in the “armor suit” then that is where our body will store toxins. After all, we aren’t using those muscles. Good storage place. And then that in turn is where illness or cancer could pop up.

I am talking about emotions: that the US culture seems to see certain emotions as “negative”. Anger, fear, grief. I asked my son what he thinks emotion is. His reply: “Chemicals?” I think emotions are neurological information. Information just as much as what our eyes see, our ears hear. If we label some emotions as “bad”, how can a child protect herself from a predator, from abuse, from a charming addict? If girls are supposed to be “nice” all the time, they have to suppress any “bad” emotions. Why would we suppress neurological information? And both my massage person and I think that stuffed emotions go into the armor suit. So toxins from the outside and toxins from the inside…. no wonder we get sick.

In the massage I am paying attention to each muscle, asking them to relax, rather then focusing on my breathing. I am also thinking that I am not sure my back is broad enough to carry what I want to carry, between work and family. I am asking the Beloved about that, sort of…. and then I have the sensation that my back is very broad. Enormous. Very very strong. I have small hips and an enormously strong back. I am 5’4″ and 130 pounds. Yet in this sensate dream, my back is as wide and strong as my friend who is 6’4″ and 220 pounds.

It’s not momentary. It goes on for thirty minutes or more. My latissimus dorsi are tight and sore, punching muscles. We talk about how we would both like to see grade school children taught to activate the slow twitch muscles, to loosen and drop the armor suit. Most of the physical education and sports are fast twitch. “Not synchronized swimming,” I say. The first formal move they are taught is to float on their back, legs straight. Hands controlling position. They slowly bend one knee and then straighten that leg up, and equally slowly lower and straighten it. This is called the ballet leg. My daughter started synchro at age 7 and had to do that at the meet. They were scored on the Olympic scoring from the start: the beginners scored in the 3 range.

“No,” he says, “synchronized swimming must use slow twitch. But that and Tai Chi are the only ones I can think of, and maybe some dance.” He says that I need to learn to release that energy: the wanting to punch, wanting to kick, instead of storing it in my muscles…. I have a heavy bag. I will make time.

I am silent, exploring the map of my back, strong and broad enough to carry much more than I thought….

This is our synchronized swimming team at our small local pool, doing the yearly show, in 2010. The five girls are in a routine and just starting a ballet leg in time to the music….