TPI Golf Seminar — Applying the Body-Swing Connection

Golf Swing TPI

I recently attended a Titleist Performance Institute (TPI) Level One seminar in Toronto to help refine my understanding of golfers, the golf swing, and how I can contribute to their swinging better and playing more. It was an exceptional two-day event led by some of the industry leaders in golf performance and fitness — Lance Gill (@LGP_Inc), Jason Glass (@jasonglasslab), and Mark Blackburn (@BlackburnGolf). Rather than write a typical review of the seminar, this will go over some of the content covered in a practical way, so you can see how it can be applied at my clinic to help you — the golfer — and your swing. Be forewarned though, this is a long article — an example of when a self-admitted “golf nerd” gets a chance to write about golf!

First, some background:

What is the Titleist Performance Institute?

TPI Certified Golf


The Titleist Performance Institute (TPI) was founded in 2003 as an entity to study how the human body influences the golf swing. They’ve built their business on the principle that there is no one way to swing a golf club, rather there is one efficient way for every golfer to swing a club, and that is dictated by what the golfer can physically do.

The Level 1 TPI Seminar revolves entirely around this concept, and much of its time is dedicated to teaching a physical screen (a battery of quick, easy, physical tests) that helps to determine what a golfer can and cannot do. In order to find the most efficient way to swing for each golfer, having this information is crucial.

It is important to understand, however, that the screening process is not meant to diagnose physical problems — merely identify them. For example, in a seated torso rotation test, the goal is to rotate the upper body 45 degrees in both directions. If you can, you have passed one screen. If you can’t, it’s simply marked that you can’t, and noted as needing further investigation — no diagnoses (ie. “arthritis of the hip”) should be conveyed.

No diagnoses are conveyed because TPI uses a three-level model for golfers to improve — anybody in these three levels could perform the TPI Screen (but not everybody is professionally trained to convey a diagnosis!). No matter who does the screening though, the first goal is identifying any physical limitations, and the second goal is to predict how it will impact the golf swing.

Maybe it’s best to describe how this works more specifically. For example, the three levels of the TPI model are:

  1. Golf Professional
  2. Medical Professionals
  3. Fitness Professionals


  • Golf Professionals can use the screen as described above. “Hmm, you can’t rotate very well during your backswing,” and they use this information to modify their instruction to suit that golfer’s particular “style”, and/or refer them on to a medical or fitness professional to start making changes to that limitation. In short, this helps golf pros make effective changes to their patrons, avoiding making recommendations that simply cannot work due to physical limitations.


  • Medical Professionals can use the screen as a jumping off point to identify physical limitations, and/or evaluate painful complaints (injuries) that are developed by golfers. “Hmm, you can’t rotate very well during your backswing. Let’s have a closer look at your hips, shoulders, and thoracic spine.” This provides a spring-board (tee-deck?) from which medical professionals can dig deeper into physical issues, get golfers back on the course quicker, and start using their newly gained physical range to improve their game.


  • Finally, Fitness Professionals can use the screen to identify physical limitations and start using forms of exercise to open up new physical capacities. “Hmm, you can’t rotate very well during your backswing. Let’s get working on getting more core muscle activation, while working your backswing under tension.” Again, this helps golfers open up new movement possibilities, and increases the efficiency, consistency, and potential in their golf game.
What else is covered?


While the TPI Screen is the object of attention at the seminar, a lot of time is also devoted to learning 12 major swing characteristics/faults in golf swings, and how the screen results can be related to these 12 characteristics. For example, much of second day was spent predicting what the swings of people at the seminar would look like based on the results of their TPI Screen. For example, John Smith failed screens A, B, and C, which suggests John will probably show X, Y, and Z swing characteristics when he golfs.

Still with me?

To make sure you understand how the screening process relates to golfers and their swings, I’m going to hold myself out as an example so you can see how a physical screen correlates with the characteristics of a golf swing. First, we’ll run over my physical screen results, break down what that might indicate, and then look to my swing and see if there’s a correlation present.

As something of an aside though, please note that this type of analysis is largely educational — for you to really understand how simple components of human movement can strongly influence sporting efficiency, you’re going to want to see a step-by-step example like this. However, when you see me professionally, my focus looks much more strongly at “What physical limitations do we have here and how do we make noticeable improvements for you, the golfer?” instead of “What swing faults are present and how do we correct the faults?” Those kind of questions are why we have golf professionals! I’m more than happy to chat about your swing (for several hours, no less), but if you are having serious issues in your golf game — see a golf pro. They are the experts in the field of golf improvement, so I’ll defer to them for swing tips. 

Put more simply: I’m the body guy; Not the swing guy.

The TPI Physical Screen


The TPI physical screen consists of 16 different components. Each one tests a different element of athletic function. There is some overlap in the tests, or redundancy, but that is an intentional feature to ensure the results of the testing is accurate. Some components are golf specific movements (it is a golf screen, after all!), but most of them are basic fundamentals of human movements that are needed in a wide variety of sports. If you have an athletic background, you’ve probably heard about “fundamentals” before; if you’re of an academic background, consider these to be movement “competencies”. Regardless of what you call it, we need know if you have the ability to do these basic movements effectively — and that’s what the screen is used to find out.

As promised then: here are my TPI screen results. Don’t worry about the specifics of what each test name is, or what the findings listed after describe. The goal of this article is not to teach you the whats and whys of the TPI screen, but to introduce the link between the screen results and the golf swing as a case study.

The Screen Results:


  1. Pelvic Tilt — FAILED, Non-smooth Motion, Neutral Tilt, Normal Range
  2. Pelvic Rotation — Pass, Good Rotation, Good Coordination
  3. Torso Rotation — Pass, Good Rotation
  4. Overhead Deep Squat — FAILED, FAILED with Arms Down, No weight shift laterally, Good Ankle Dorsiflexion Bilaterally
  5. Toe Touch — Pass
  6. 90/90 — Equal to spine angle standing, Equal to spine angle in golf posture
  7. Single Leg Balance — 16-20 seconds bilaterally
  8. LAT Length Test — FAILED, Right arm covers the nose, Left arm between nose and wall
  9. Lower Quarter Rotation — Backswing FAILED left and right less than 60 degrees, Downswing passed left and right 60 degrees or more
  10. Seated Trunk Rotation — Greater than 45 degrees bilaterally
  11. Bridge w/ Leg Extension — FAILED left glute weak, Passed right glute
  12. Cervical Rotation — Passed bilaterally
  13. Forearm Rotation — Passed greater than 80* bilaterally
  14. Wrist Hinge — Normal bilaterally
  15. Wrist Flexion — Normal bilaterally
  16. Wrist Extension — Normal bilaterally
  • Extra Test: Reach Roll and Lift Test — FAILED, Left arm between ground and ear, Right arm can’t lift off ground
What stands out?


I know that was way too much information listed above! To make things more obvious, here are the TPI screen’s most significant findings :

  • Overhead Deep Squat
  • Lower Quarter Rotation Test
  • Bridge w/ Leg Extension
  • Pelvic Tilt
  • Reach Roll and Lift, Lat Length Test

These represent the screens I had the most difficulty with — so we should be able to predict what my swing will look like in real-time based on this information. This is possible because we understand which swing characteristics most commonly present when certain physical limitations are found (per research conducted by TPI) and because we follow what basic anatomy demands to be true in human movement. For example, data collected by TPI research indicates that more than 90% of golfers with a failed Overhead Deep Squat test will early extend during the golf swing. That is a strong correlation! 

Don’t know what early extend means? That’s ok — let’s break down the significant findings above and see if we can draw some predictions for what my swing will look like:

  • As it happens, I did fail the Overhead Deep Squat test, so in my case early extend is highly probable. This means there’s a good chance you’ll see my hips drift towards the ball during the backswing, downswing, or both. This fault is likely compounded by my failure of the Pelvic Tilt Test, which suggests uncontrolled or poorly controlled motion at the pelvis. All in all, you should expect that I will move closer to the ball during the swing.


  • Other important outcomes from my TPI screen, like the Lat Length Test and Reach, Roll, and Lift Test, are both measures of shoulder flexion — ie. how well am I able to get my arms overhead? (Clearly, not very well!) Both sides (left and right) did not meet the basic minimums we expect to see in golfers, and the right side was scored particularly miserably on both of these screens. As a result, it’s probably fair to say you should not expect to find me in a classic backswing position where the arms are held high overhead at the top — at least not without using some other compensations to get there.


  • For example, things like “loss of posture” or a “reverse spine angle” are compensations that could be expected if I can’t raise my arms overhead. Why? If my arms are physically incapable of reaching above my head, I might lean my body towards the target during the backswing (creating a “reverse spine angle”), giving the false sense that I now have my hands in a proper position. Alternatively, a loss of posture could also occur, where I either stand up and away from the ball or lean down towards the ball during the backswing, again trying to make up for lost range of motion at my shoulders. Either of these swing characteristics may present in an unconscious attempt to compensate for my limited shoulder range of motion.


  • Finally, take these findings and couple them with limited hip rotation into the backswing (as noted by the Lower Quarter Rotation Test), and you might expect me to have even more difficulty completing a backswing. Golfers with hip rotation limitations will commonly sway (during the backswing) or slide (during the downswing) the pelvis to make up for a limited ability to rotate the hips.
So… you’re not very good.


I’m sure by now you have a mental picture my swing that must be terrible! With so many physical restrictions highlighted by the TPI Screen, I must not be very good at golf, right?

In reality, I’d wager I’m a better golfer than you think! I don’t carry an official GAO handicap anymore, but the last few years I’ve played to a mid-70s average on courses in the west end of the GTA and Hamilton. I’m no pro — but I’m not terrible, either.

This presents a good time to insert a strong reminder about how the TPI screen works:

  1. Don’t be alarmed when numerous possible “faults” become apparent. Every golfer is a person, and every person has unique limitations or variations in how they move. Should they aim to be able to perform the minimum movements described by the screens? Sure!… for good physical health. But the number of physical limitations on a screen doesn’t correlate perfectly with golfing ability because…
  1. You should always keep the basic TPI philosophy in mind:

“We do not believe in one way to swing a club, rather in an infinite number of swing styles. But, we do believe there is one efficient way for every player to swing and it is based on what the player can physically do.”

This principle is critically important to remember at all times because…

  1. We’re not identifying and fixing your physical limitations so that we can build a perfect swing. We’re doing all this to open up new possibilities in your golf game — to make your swing the most efficient, powerful, and repeatable that it can be. Ask yourself: would you change Jim Furyk’s golf swing? I know I wouldn’t — that’s a multi-million dollar swing! There are many examples of touring professionals who, based on the screening process, have serious physical limitations — and yet they are still highly successful!
Back to the Assessment — Link it to a Swing


One quick note here: this section is the realm of the golf professional — one of whom I am not! TPI Certification provides a cursory understanding of golf swing biomechanics and assessment so that any TPI Certified Professional you talk with about your swing will have the same basic understanding, but as discussed earlier this does not make me an expert! In a professional setting, breaking down your swing and offering specific tips for improved play is moving outside my expertise — you should consult a Golf Professional for that.

Having said that, this is just for a blog posting (not a professional assessment) so let’s go through the process anyways.

A reminder of the things that we predicted might be seen based on the physical screening:

  • Limited control of the hips/pelvis (sway/slide/early extension)
  • Limited hip rotation during the backswing (same as above)
  • Limited shoulder flexion (short backswing/loss of posture)

So if my physical limitations dictate how I swing a golf club, they should be reflected in the videos I’m about to show you.



The two images above should play short videos of my swing from down-the-line and face-on views (they are .gif files). Both videos were recorded on an iPhone 5, using the Hudl Technique app. Higher quality video capture is probably ideal (newer phones are really, really good), but this works for me.

A quick summary of the things we might be looking for in the down-the-line view:

  1. S-Posture
  2. C-Posture
  3. Loss of Posture
  4. Flat Shoulder Plane
  5. Early Extension
  6. Over-the-Top


A quick summary of the things we might be looking for in the front-on view:

  1. Sway
  2. Slide
  3. Reverse Spine Angle
  4. Hanging Back
  5. Casting/Early Release/Scooping
  6. Chicken Winging


More detailed information about these can be found on the Titleist Performance Institute website. I won’t detail all of them here because TPI does a great job describing each one individually — just click on the links — and it’s not my area of expertise. I’ll just discuss some of the common things relevant to my swing as we come to them. 




Down the Line Swing


Don’t be afraid of lines! Let’s make sense of them:

A posture line is drawn connecting head to hips, hips to knees, and knees to ankles. Ideally, these lines stay connected with the same body parts throughout the swing. You can see in my half-way back picture on the right that my head and body are already moving below my posture line (towards the ball). This is an example of the loss of posture characteristic — but we’ll get to a full analysis in a minute.

Also drawn are a line down my clubshaft at set-up (left image), and a line down the clubshaft at half-way back (right image). The space between these lines is considered the swing “slot”. Theoretically, the club should be delivered in this space during the downswing.

Finally, a single vertical line is drawn at the back of my pelvis. Since the pelvis is elliptical in shape, as it rotates it should never leave this line. For example, as my pelvis turns to the left, my left buttock should stay in contact with this line, and as I turn to the right, my right buttock should stay in contact with this line. If this doesn’t happen — if space appears between my pelvis and this line at any time during the swing — this is a sign of early extension.

Let’s put a few images together then:

Doewn the Line Series

Following the pictures from A-E, here are the most obvious swing characteristics noted:

  • Loss of Posture. Compare where the posture line passes through the head and hips in Image A, and the through the rest of the pictures. It’s pretty clear that I’ve dropped my torso down, towards the ball, basically from the very start of my backswing — and maintained that dropped position throughout the swing.


  • Early Extension. Follow the vertical line at the back of the pelvis throughout the pictures. I stay in contact during the backswing, but as soon as the downswing starts (the red arrow in Image C) my left hip pulls away from the vertical line. It stays like this throughout the swing, and the right hip doesn’t even come close to making contact at any point. That’s a clear, textbook example of early extension — which really shouldn’t be surprising since we mentioned earlier that 90% of people who fail the Overhead Deep Squat test show early extension in their swing (and I failed it in spectacular fashion).


  • Over the Top. Slicers everywhere, rejoice! I’m with you. It’s not as dramatic as you’ve probably seen other golfers exhibit at some courses, as I almost stayed within the “slot”, but it is an example of a swing fault nonetheless. Look at the red line in Image C, and you can see how halfway into the downswing my clubshaft is crossing the slot-line. More pronounced examples of this swing path will produce the classic “Banana-ball” shot shape — though in an entirely self-serving move, I’d like to take this opportunity to point out that my typical shot-shape is a soft fade (no bananas!).
The Face-On View:


Face On Swing


More lines! Fortunately, there are fewer things to pay attention to here.

Three basic things:

  1. A line drawn up the outside of my trail ankle to the outside of my trail hip. In simple terms, you don’t want to move away from the ball during the backswing. Staying still allows the golfer to load power into the trail side during the backswing and transfer that power during the downswing. If the trail leg or hip moves away from the ball during the backswing, that is a sign of sway.
  1. A vertical line drawn at the outside edge of my lead ankle represents the general boundary of how far the hips can move forward during the downswing. Again, the lead leg or hip moving past this line towards the target doesn’t allow a golfer to push against anything (like the ground) during the downswing and reduces how much power can be transferred to the ball. This would be a sign of a slide.
  1. The final line here is simply a hip line, drawn at the level of the hips during setup. It’s more a reference than anything, which can be used to evaluate things like casting the club during the downswing.

Again, let’s put a few images together:

Face On Series

The most obvious things seen here:

  • The front and back lines drawn to assess sway and slide actually stay relatively untouched in these pictures. If you remember, the physical screening suggested I might sway or slide to make up for limited hip rotation in the backswing, and some pelvic control issues. Instead, we find that my trail side is very stable during the backswing, and the lead side is pretty good. However, during the downswing, the lead leg does break the plane of the line ever so slightly. So while this is probably far better than we could anticipate it to be given the results of the TPI Screen, in my opinion this still represents a subtle slide characteristic.


  • Image H has extra lines and boxes as a quick check on reverse spine angle. This is another possible swing characteristic that presents with limited backswing ability in golfers — if you can’t get the arms overhead, sometimes leaning towards the target makes up that range of motion to complete the backswing. If that were happening, the line drawn to connect the two boxes would point towards the target (to the left) — here, it doesn’t (hooray!).

(It should be noted that 2-D analysis (like this) isn’t the best for assessing reverse spine angle though, as 3-D analysis and motion capture is much better.)

  • There are other characteristics you can assess from this view, but they have been skipped over because they aren’t directly related to my swing. For example, things like casting, scooping, early release, hanging back, etc, could all be evaluated from a face-on view. I don’t see any evidence of these at this time — but again, I’m a medical professional — not a golf professional! — and I’m going to defer to the golf professional’s opinion regarding any uncertainty or disagreement in swing analysis.
Put it All Together


Have another look at the full swings again — no lines.



Now another review of what we expected based on the physical screening:

  • Limited control of the hips/pelvis (sway/slide/early extension)
  • Limited hip rotation during the backswing (same as above)
  • Limited shoulder flexion (short backswing/loss of posture)

And now the things we found looking at some pictures:

  • Loss of Posture
  • Early Extension
  • Over the Top 
  • Short Backswing
  • Possible Slide

That’s pretty close, right? And it certainly makes sense that our physical abilities will predict how an athletic move, like swinging a golf club, ends up being executed.

But you didn’t perfectly predict the swing. You predicted sway, slide, and a reverse spine angle.


That’s true, but just having my TPI screen and pictures of my swing doesn’t give you my complete story. I’m an individual too, and while you might expect me to complete a backswing by swaying off the ball or leaning towards the target because I struggle to raise my arms overhead and rotate my hips into the backswing, you’re missing something.

What you don’t have is my unique golf history; the conscious efforts I’ve made over the years that helped create my own unique swing. In this case, I’ve spent literally years working to not sway off the ball during my backswing, and generate enough power from within a shorter-than-most backswing. I’ve always felt (rightly or not) that if I didn’t “move” during the backswing, I made better contact with the golf ball, creating easy power and a consistent ball-flight. As this has been a key fundamental of mine for more than a decade now, I think it probably contributes strongly to why my swing stays short, but without evidence of the swing characteristics like sway, or reverse spine angle. (A quick hat tip is needed here to an old mentor for helping me develop these concepts. Thanks Ted!)

In Conclusion


I’m at high risk of straying far from my “Medical Professional” territory if I keep writing more (!), so it’s probably time to pull the chute on this post.  

I think you can see the relationship between the TPI screen and the characteristics seen in a live golf swing. That link (the “Body-Swing Connection”) is the heart of what TPI screening provides — identification of physical abilities, and their relationship to the swing itself.

But as noted earlier, I’m the body guy — not the swing guy. If I had just assessed my case in the clinic, next steps would involve a deeper investigation into how the hips move, what kind of motor control I have at the pelvis and glutes, and what the heck is going on with that shoulder function. With specific treatment and exercise interventions, I’m confident you would see improved swing characteristics that could also manifest as bigger drives, better scores, and fewer injuries. 

(Although I’m sure four-foot putts would still haunt me, even after all that.)

I’m sure there are questions here — despite how much was written I’ve left a lot out too! Feel free to send them my way, and drop a comment below.

Dr. Jim GilliardDr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre— located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000


Temporomandibular Joint (TMJ) Pain

Your Jaw – the Temporomandibular Joint

Painful joints frequently frustrate patients — they are unable to do what they want, when they want, or how they want to do so. But in my experience, the most frustrated patients do not have a sore neck, back, shoulder, or knee. No, the most frustrated patients present with a painful jaw. Jaws can be significantly painful and present major barriers to everyday life — but even more significant for many patients is the frustration that comes from having so few options available for treatment!

With that in mind, today we review temporomandibular joint (TMJ) pain, breaking things into a few components:

  1. What is the TMJ?
  2. Who is impacted by TMJ pain?
  3. How did I end up with TMJ pain?
  4. Why does my TMJ make noises?, and
  5. Does Manual Therapy (like Chiropractic) help with TMJ problems?

What is the TMJ?


The joint that makes your jaw, called the temporomandibular joint (TMJ), is located immediately in front of the ears. Two bones create this joint: the bone from your chin (the mandible), and a bone from your skull (the temporal bone). This joint is responsible for allowing movements of the jaw, like protrusion (sticking the chin forward), retraction (drawing the chin backwards), lateral deviation (moving the chin side-to-side), and opening or closing. Each of these motions is important for common daily functions like chewing, talking, swallowing, etc.

Although the TMJ looks like it is shaped similarly to the shoulder (a “ball in socket” joint), it is actually more complicated. An articular disc is located between the two bony surfaces of the TMJ, which divides the joint into superior and inferior (top and bottom) parts. As a result, to move properly during mouth opening, the jaw must first rotate during opening (the mandible rotates on the disc — bottom part of the joint), and then glide forward to complete opening (the mandible and disc glide on the temporal bone — upper part of the joint).

To understand this better, follow these steps:

  1. Place your fingers on the condyle of your mandible (the round “knob” immediately in front of your ears). Keep your fingers here throughout this exercise.
  2. Now place your tongue on the roof of your mouth, and attempt to gently open you jaw. You should notice that very little changes — this is the mandible rotating on your disc!
  3. Remove your tongue from the roof of your mouth, and continue opening the jaw. You should notice a large change here — the condyles of your mandible slide forward, together with the disc, as your jaw opens completely!

This is a rather complicated process, but consider if the disc wasn’t present, and we were only able to rotate at the jaw (the first half of the exercise) — we would have a very limited ability to open our mouth wide!

Each step in this process is controlled by our muscles of mastication (chewing muscles): the temporals, masseter, medial pterygoid, and lateral pterygoid (pronounced TARE-uh-goid). The joint is also supported by ligamentous structures, including the joint capsule and temporomandibular ligament, stylomandibular ligament, and sphenomandibular ligament.

Who is impacted by TMJ pain?

According to the National Institute of Dental and Craniofacial Research, the prevalence of temporomandibular joint problems (the number of active cases at any given time) ranges between 5-12% of the population — so this is not an uncommon problem for people. Women appear to suffer from TMJ problems more than men, and younger populations have a greater number of cases than older populations.

How did I end up with TMJ pain?

Usually, these problems are attributed to a mechanical dysfunction (improper muscle action), direct trauma to the TMJ (striking or being struck by something), bruxism (grinding your teeth), or asymmetrical use of the jaw (chewing on one side only). Other factors can lead to jaw pain as well, but typically at least one of these are involved.

Regardless of how it occurred though, your TMJ complaint likely falls into one (or more) of these four categories:

  1. Muscle Related Pain
  2. Joint Related Pain
  3. Degenerative Joint Disease
  4. Headache related to TMJ Disorder

These categories are broadly established by the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), published by Schiffman et al. (2014) in the Journal of Oral & Facial Pain and Headache. (There are specific subcategories to the DC/TMD, but that moves beyond the scope of this posting — if interested, it is publicly available here)

Why does my TMJ make noises?

Sometimes, when people open their jaw fully, it is accompanied by one or more noises or sounds. Some people experience “clicking”, “popping”, or “grating” (like grinding). So why is that?

As discussed previously, the TMJ is a complicated joint — there are numerous muscles pulling in different directions, a delicate relationship to maintain between the mandible and temporal bones, and a disc which buffers and supports movements at your jaw. Each of these components needs to work as intended, at the right time, and in the correct balance for proper movements to occur.

TMJ Lateral Pterygoid
Upper arrow: superior head of lateral pterygoid. Lower arrow: inferior head of lateral pterygoid.

For example, let’s consider how the jaw should function. We know that rotation occurs first, and then the mandible glides forwards for complete opening of the jaw. This happens because the lateral pterygoid muscle has two attachments: the superior head attaches to the disc itself, and the inferior head attaches to the mandible. When this muscle contracts to begin jaw opening, therefore, the disc slides forward slightly to partially block the mandible from moving forward — meaning the pull of the lower head only creates rotation initially. During the self-test described earlier, this is the phase where your tongue remains on the roof of your mouth.

However, when the forces become greater, both the disc and mandible move forwards together, on to the front aspect of the joint — something called the “anterior eminence”. Here, the disc is acting strictly as a buffer, providing a more stable contact surface for the mandible. Without the disc here, we would be much more prone to jaw dislocations. (See image below).

TMJ mechanics

But so what, right? How does this relate to the noises your jaw makes?

Each of these actions needs to work as designed — otherwise, noises sometimes occur:

  • The disc doesn’t reset properly, and sits slightly forward at the beginning of opening? This may cause the mandible to slide over the posterior part of the disc — CLICK!
  • You’ve already clicked on opening, and now as you close the mandible shifts backwards out of sync with your disc just as you complete the closing of your jaw — CLICK!
  • And if you’re really having an unfortunate time, the disc gets stuck on the anterior eminence, blocking the mandible from even getting to the gliding stage — now you can’t even open your jaw!

Any number of reasons could cause one of these dysfunctions to occur: poor muscle function, irritation of the joint or joint structures, sudden impact to the jaw, changes to the structure of the joint (like arthritis), etc.

But despite having gone through all of the above, let me be very clear about this final point: sometimes joint noises are simply idiopathic, which means their cause is unknown! Noises on their own are common (lots of people have them) and they don’t necessarily indicate a problem or clinical dysfunction of your jaw. So if you notice you have jaw noises, but no pain or limited movement, please do not conclude from this blog posting that you have a TMJ dysfunction — clinically, it might not mean anything at all!

Does manual therapy help with TMJ problems?

What we’ve seen:
  • For what it’s worth, we’ve seen a number of TMJ complaints resolve successfully using manual therapy based treatments in our office. This means treating TMJ conditions with a combination of hands-on approaches like muscle massage, stretching, and joint mobilization, and supplementing this approach with other tools like laser therapy and acupuncture. We are thrilled to see consistent results for patients using this approach, but we understand that more objective information is available in the scientific literature too — so here it is.
What the research shows:
  • Manual therapies targeting musculoskeletal approaches to TMJ have been found to be effective for dealing with TMJ problems. For example, a recent systematic review and meta-analysis by Martins et al. (2016) reviewing this type of approach to treating TMJ disorders (things like massage or joint mobilization/manipulation) found significant and clinically important improvements in jaw range of motion and reduced painful complaints when compared to other forms of conservative therapy (like stretching, hot/cold application, modality use, etc). This means both the intensity of the patient’s pain and functional limitations were improved with a manual therapy approach to treatment.
  • Another systematic review of trials using manual therapy to treat TMJ disorders (from Calixtre et al., 2015) indicates that manual massage to jaw musculature coupled with cervical spine mobilization or manipulation produces favourable patient outcomes too (decreased pain, increased jaw range of motion). Again, this supports the use of manual therapy to the TMJ for reducing pain and improving function, but also hints at the added effect that treatment to surrounding areas, like the neck, can also offer.

And what about the adjunctive treatments we employ?

  • Laser therapy has demonstrated success in improving treatment results for TMJ complaints. Chen et al. (2015), for example, recently completed a meta-analysis of 14 high quality studies, concluding that laser therapy can significantly improve functional outcomes of TMJ disorders.
  • Acupuncture has also been demonstrated to produce a positive effect for TMJ conditions, though there is more debate about how much and to what degree depending on which studies you review. A meta-analysis submitted by Jung et al. (2011) in the Journal of Dentistry, for example, describes limited evidence for acupuncture effects on TMJ disorders – but the general trend leans towards favourable effects of acupuncture as compared to sham treatment*, particular for reducing muscle tenderness.
  • Even the much-maligned ultrasound therapy has shown some evidence of improving TMJ complaints, as a study published by Ucar et al. (2014) demonstrates. They compared groups of patients with TMJ complaints receiving home exercise program alone to a home exercise program in conjunction with ultrasound therapy to the jaw and surrounding muscles, finding that pain relief and mouth opening ability were both greater for the group receiving ultrasound therapy with exercise.

Sham treatment clarification

What this means:

Yes. To put things more simply, adding manual therapy targeting the TMJ and surrounding muscles can provide a tangible benefit for jaw complaints. While true that each individual therapy may not solve a TMJ complaint on its own, there is a significant body of research that supports hands-on manual therapy and adjunctive modality use, at least in some regard, for the treatment of TMJ disorders.

In Summary:

  1. Your jaw has a complicated but specific pattern of movement needed to work properly.
  1. Alterations to this pattern can lead to noises, pain, and limited jaw function — but it’s also important to remember than some jaw noises are idiopathic.
  1. A relatively common problem, TMJ disorders appear more often in younger than older individuals, and women more than men.
  1. Manual therapy, like the treatments provided by chiropractors, continues to develop a growing body of evidence for its effectiveness in treating TMJ disorders.

Dr. Jim Gilliard

Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre— located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000

Primary References
  1. Calixtre LB, Moreira RFC, Franchini GH, Alburquerque-Sendin F, Oliveira AB. Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: A systematic review of randomised controlled trials. J Oral Rehabil. 2015;42(11):847–61.
  2. Chen J, Huang Z, Ge M, Gao M. Efficacy of low-level laser therapy in the treatment of TMDs: A meta-analysis of 14 randomised controlled trials. J Oral Rehabil. 2015;42(4):291–9.
  3. Jung A, Shin B-C, Lee MS, Sim H, Ernst E. Acupuncture for treating temporomandibular joint disorders: A systematic review and meta-analysis of randomized, sham-controlled trials. J Dent. Elsevier Ltd; 2011;39(5):341–50.
  4. Martins WR, Blasczyk JC, de Oliveira MAF, Lagoa Goncalves KF, Bonini-Rocha AC, Dugailly PM, et al. Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis. Man Ther. 2016;21:10–7.
  5. Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet J-P, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain Headache [Internet]. 2014;28(1):6–27.
  6. Ucar M, Sarp Ü, Koca İ, Eroğlu S, Yetisgin A, Tutoglu A, et al. Effectiveness of a Home Exercise Program in Combination with Ultrasound Therapy for Temporomandibular Joint Disorders. J Phys Ther Sci. 2014;26(12):1847–9.

A Simple Exercise for Your Neck Pain


Our neck is extremely adaptive. Look up and down, left and right, or any combination of those movements and you get a sense of just how much freedom of movement we have.

But as with any body part, using it in a similar ways consistently leads to adaptive changes. Consider “text neck”, looking down at our smartphones and tables for long periods of time each day, or office workers hunched forwards and leaning it at their computers. Either of these static positions can lead to a forward head position and/or rounded shoulders.

Bad posture - neck pain


Carrying your head in front of your body becomes extremely taxing on the muscles and joints. Obviously we are built with enough strength and stability to support the general movement of our head and neck, but when we start these movement with our head already set forward, we amplify the amount of stress our body has to deal with!

In particular, the muscles at the front of the neck, called the “deep neck flexors”, play a critical role in neck stability and posture control. The function of these muscles becomes limited as our posture begins to show a forward head position. This is bad! Past studies have shown that 70% of patients with chronic neck pain have limited muscle function of the deep neck flexors (Yip et al. 2008).

And where the muscles at the front turn off, muscles at the back of the neck and upper back are required to work much much harder. Some have suggested that for every inch forward your head moves, it is the equivalent of 10 additional pounds of work required by the muscles at the back of the neck and upper back (Kapandji, 1974). Other mechanical models (depicted in the image below) suggest that by tilting your head to just 45 degrees, the total weight that needs to be supported increases from ~10 pounds to ~50 pounds (Hansraj, 2014). This is often reflected in patients who present with achy muscles and joints, and increased headaches (Fernandez-De-Las-Penas et al. 2006).

Neck forces - neck pain
From Hansraj, KK (2014).


It has been demonstrated that simple exercises for the deep neck flexors are very effective for resolving chronic neck pain and headaches. (Chiu et al. 2004; Jull et al. 2009). These exercises focus on redeveloping control and use of the deep neck flexors at the front of the neck. Kim et al. (2016) recently published an article following a group with chronic neck pain where they performed deep neck flexor exercises 3 times per week for 4 weeks, finding significant improvements in their overall pain rating and fewer functional limitations. And that is exercise on its own — imagine the effects when combined with other helpful therapies, like chiropractic (Bronfort et al. 2012), massage (Sherman et al. 2014), and/or acupuncture (Vickers et al. 2013)!


The deep neck flexors exercise is extremely simple, and can be done nearly anywhere. When learning this exercise, the easiest position is laying on your back, face up, in a comfortable position, usually with the small towel behind the head and knees bent. There are a couple of descriptions given to patients — each with the same end goal — but you can select the description that makes the most sense to you.

  • Exercise description A: Slowly feel the back of their head slide up the floor in a head nod action.
  • Exercise description B: Slowly nod the head in an action indicating “yes”.
  • Exercise description C: Slowly draw your nose straight backwards, so that you give yourself a “double-chin”.

Deep Neck Flexors Exercise

The second stage — and the one people find more convenient — is to do these exercises sitting up. The same principles apply: head slides up in nodding action, nod to say “yes”, draw nose back and make a “double-chin”, etc. The benefit here is that you can do these anywhere. A lot of people find this exercise fits into their day much better — sitting at a stoplight in the car, at a transit stop on the train, or between emails at work. No equipment required, no obvious exercise position assumed — all you need is 10 seconds of your time.

The general aim is for a 10 second hold, repeated 10 times consecutively. Each case is unique, however, so you should always seek advice from a health professional to determine your specific needs.

If you would prefer a video to see an exercise for the deep neck flexors, here you go.

IN CONCLUSION – Your Deep Neck Flexors

If you are dealing with chronic neck pain or headaches, these exercises for the deep neck flexors have been shown to be beneficial in reducing pain and returning patients to better function. They are simple, equipment free, and discrete movements that make them ideal for beginning the road to recovery. Be sure to visit a health professional for a proper diagnosis though, and combine these exercises with other effective treatment options.

Dr. Jim Gilliard

Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre— located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000

  1. Bronfort G, Evans R, Anderson A V, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Intern Med. 2012;156:1–10.
  2. Chiu TTW, Lam T-H, Hedley AJ. A randomized controlled trial on the efficacy of exercise for patients with chronic neck pain. Spine (Phila Pa 1976). 2005;30(1):E1–7.
  3. Fernández-De-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Trigger points in the suboccipital muscles and forward head posture in tension-type headache. Headache. 2006;46(3):454–60.
  4. Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014;25:277–9.
  5. Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man Ther. 2009;14(6):696–701.
  6. Kapandji, I. A. “The Physiology of the Joints, vol. 3.” The trunk and the vertebral column 2 (1974).
  7. Kim JY, Kwag K Il. Clinical effects of deep cervical flexor muscle activation in patients with chronic neck pain. J Phys Ther Sci. 2016;28:269–73.
  8. Sherman KJ, Cook AJ, Wellman RD, Hawkes RJ, Kahn JR, Deyo RA, et al. Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain. Ann Fam Med. 2014;12(2):112–20.
  9. Vickers AJ, Foster NE. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444–53.
  10. Yip CHT, Chiu TTW, Poon ATK. The relationship between head posture and severity and disability of patients with neck pain. Man Ther. 2008;13(2):148–54.


Migraine Headaches

migraine headache

How do I know if I have a migraine?

Migraines are an awful, unwanted condition that nobody wants to experience. They can be short-lived (a few hours) or persistent (multiple days!).  Depression, irritability, neck stiffness, visual flashes of light, pins and needle sensations, sensitivity to sound and light, nausea and vomiting, and of course, severe headache are all examples of symptoms that may come with a migraine. Yikes. Here are a few more, too. Sometimes these symptoms appear before the headache (premonitory symptoms and aura), during the migraine, and/or after the headache (postdromal symptoms).

But migraines usually have a few typical characteristics. According to ICDH-3 classification, migraines can either occur with or without an aura (more on that later). To properly diagnose these forms of migraine, patients have to experience a headache within the confines of a standard migraine description:

  1. At least five attacks fulfilling the following,
  2. Headache lasting 4-72 hours
  3. Headache with at least two of the following four:
    1. Unilateral Location (one-sided)
    2. Pulsating quality
    3. Moderate to severe intensity
    4. Aggravation by or causing avoidance of routine physical activity
  4. At least one of the following two
    1. nausea and/or vomiting
    2. sensitivity to light and sound

An aura is a complex of symptoms that usually occur before a migraine begins. (These are complicated neurological phenomenon, and could take several blog postings to themselves!) Most of the time (90% of patients) aura symptoms are visual (generally a bright spot with visual disturbance), but they can also be sensory (usually pins, needles, or numbness), speech, or motor symptoms — however these types of symptoms are less common. Linked is an excellent video describing the symptoms of migraine aura, from the Mayo Clinic. Once again, the ICDH-3 classifications require at least two of the following four characteristics:

  1. At least one aura symptom spreads gradually over 5 minutes, and/or two or more symptoms occur in succession.
  2. Each unique aura symptom lasts 5-60 minutes.
  3. At least one aura symptom is unilateral.
  4. The aura is accompanied, or followed within 60 minutes, by a headache.

But what IS IT exactly?

There is little evidence that blood flow changes are occuring at the brain cortex if you do not experience aura symptoms. For migraines with aura symptoms however, there is clear evidence that blood flow changes at the cortex are occuring

Migraines without aura and migraines with aura are complicated biological processes, with what appear to be distinct differences between them. For example, it was long believed that poor blood flow to the brain (vascular supply to the cortex) was a key element in the reason for both types of migraines. However, if you don’t have an aura, this no longer appears to be the key factor. Instead, chemical disturbances, sensitization of pain pathways, and central nervous system involvement are suspected to be the primary players — there is little evidence that blood flow changes are occuring at the brain cortex if you do not experience aura symptoms.

For migraines with aura symptoms however, there is clear evidence that blood flow changes at the cortex are occuring. Regional blood flow usually becomes diminished in the back of the brain first, gradually spreads towards the front, and is followed by a period of excess blood flow to the same areas later. These changes are closely related to the time at which aura and migraine symptoms are experienced.


Am I suffering Alone?

Using Statistics Canada information from 2010/11, Ramage-Morin and Gilmour (2014) state that 8.7% of Canadians (2.7 million) reported being diagnosed with a migraine by a health professional. Females reported greater prevalence than men, at 11.8% vs 4.7%, and the highest prevalence was among people aged 30-50 (17% of women; 6.5% of men).

The authors also note how migraine sufferers are impacted at work. They suggest that 36% of migraine sufferers missed at least one day of work in the most recent 3 months due to their migraine, and nearly one in five needed to change their work activities for at least three month due to their migraines (type, duration, all activities)! This supports previous investigations suggesting that it is the lost productivity while at work that impacts people more than true absence from work. (So generally it’s not that migraine prevent people from going to work, it’s that workers are significantly impaired in their productivity once they get there because of their migraine).

How do I Stop or Prevent Migraines?

Obviously, migraines are a big problem a lot of people. With problems of this size and complexity, we often can’t limit our treatment strategies to a single source. As such, here are five unique avenues you might consider exploring to help manage your migraines.

1> Chiropractic Care

Seeking treatment from any health professional is always advisable when trying to find options to eliminate a health concern. When visiting a chiropractor, parts of your body that may be contributing to migraine symptoms can be addressed, usually with muscle massage, joint mobilization, adjustments, and other therapeutic tools like electrical stimulation. A Cochrane review from 2004 compared chiropractic treatment for migraines (specifically SMT and electrical modalities) directly to a commonly used drug for migraines (amitriptyline). This review established that chiropractic treatment delivers similar successful outcomes to the prescribed drug treatment — making it clear that chiropractic is an effective and viable option to manage migraines.

2> Acupuncture

Similarly, the effect of acupuncture treatments on migraines have also been studied. Another Cochrane review from 2009 reviewed the effectiveness of acupuncture for migraine prophylaxis (prevention), concluding that “there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care[…]” and “acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects.”

That’s a pretty strong indication that for people with migraines, acupuncture may be a very useful tool for limiting the number of future occurrences.


3> Self-Regulation Strategies

Self-regulation strategies are beginning to play a more prominent role in patient management for a number of health conditions. Migraines are well suited to be managed in part by mindfulness based interventions (like meditation, deep breathing, and self-awareness activities) as promising findings are being recorded with diminished migraine duration and migraine-related disability. Furthermore, mindfulness based interventions are also exhibiting positive outcomes for stress, depression, anxiety, and insomnia — all common secondary distresses for those suffering from migraines. (Smitherman et al. 2015)

4> Using Caffeine as a Boost

We’ve previously discussed caffeine as an adjuvant (booster/beneficial additive) to medication use to decrease painful conditions, and it appears this applies to migraines too. Using caffeine in combination with medication consistently shows improved resolution of painful symptoms as they relate to migraine or migraine-like symptoms. (Derry et al. 2012)

Of course, medication interactions are something that should be avoided if possible — so before you start consuming a cup of coffee with each of your medications, be sure to speak to your doctor or pharmacist first. Safety first!

5> Magnesium Supplementation

There is a theory that at least some migraine sufferers may be deficient in magnesium, and that this deficiency may contribute to their migrainous symptoms. To this end, the impact of magnesium supplementation on migraine prophylaxis has been studied, and although the results are at least promising, they are largely inconclusive.

A recent review of magnesium supplementation for migraine prevention notes that while magnesium intakes are below the estimated average requirement levels for nearly 50% of the United States, and a deficiency could lead to neuronal injury and/or altered chemical activity in the brain (possibly leading to migraine symptoms), the evidence supporting magnesium supplementation for prevention of migraines remains limited at this time. They do, however, note that “limited evidence” means dietary supplementation of magnesium may still be advised if patient’s are looking for preventative measures. (Teigen & Boes, 2015)

Where can you find magnesium in food? Green leafy vegetables like spinach and kale, beans, grains, seeds, nuts, and some seafood all contain magnesium in more significant quantities — so it is pretty easy to find! For a more complete list, follow the link here (Dietitians of Canada, 2015).

BONUS idea – Menthol (Peppermint)

Another intervention we have previously talked about, menthol has demonstrated effectiveness for managing migraine symptoms as well. In particular, a 10% ethanol solution of menthol applied to the forehead and temples was used. So there you go — peppermint, not just for the holidays! (Borhani Haghighi et al. 2010)

Dr. Jim Gilliard

Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre— located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000

Primary References:
  1. Borhani Haghighi A, Motazedian S, Rezaii R, Mohammadi F, Salarian L, Pourmokhtari M, et al. Cutaneous application of menthol 10% solution as an abortive treatment of migraine without aura: A randomised, double-blind, placebo-controlled, crossed-over study. Int J Clin Pract. 2010;64(4):451–6.
  2. Bronfort G, Haas M, Evans R, Goldsmith C, Assendelft W, Bouter L. Non-invasive physical treatments for chronic/recurrent headache (Review). Cochrane Database Syst Rev. 2004;(8).
  3. Derry CJ et al. Caffeine as an analgesic adjuvant for acute pain in adults. Cochrane Database Syst Rev. 2012;(12).
  4. Köseoglu E, Talaslioglu A, Gönül AS, Kula M. The effects of magnesium prophylaxis in migraine without aura. Magnes Res. 2008;21(2):101–8.
  5. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White A. Acupuncture for migraine prophylaxis (Review). Cochrane Database Syst Rev. 2009;(1).
  6. Olesen J et al. The International Classification of Headache Disorders, 3rd edition. Cephalagia. 2013;33(9):629–808.
  7. Ramage-Morin PL, Gilmour H. Prevalence of migraine in the Canadian household population. Health Reports. 2014;25(6):10–6.
  8. Smitherman TA, Wells RE, Ford SG. Emerging behavioral treatments for migraine. Curr Pain Headache Rep. 2015;19(13).
  9. Teigen L, Boes CJ. An evidence-based review of oral magnesium supplementation in the preventive treatment of migraine. Cephalalgia. 2015;35(10):912–22.

Photo Credits under Creative Commons:

A New Muscle!

Tensor of the Vastus Intermedius
Photo credit Athikhun.suw via Wikimedia Commons

World, meet the Tensor of the Vastus Intermedius!

Hot from the desk of Cool New Things: in a pre-published article submitted to the journal Clinical Anatomy (2016), a group of researchers in Switzerland have determined they have identified a new muscle in the thigh! This muscle becomes part of the quadriceps groups, beginning in the upper-outer part of the thigh and travelling to the knee.

A bit like when you learned Pluto was no longer a member of the planets, anatomy very rarely produces entirely new structures, or redefines known parts of the body. Variations are often noted, but identifying a new muscle is unique. So let’s outline what is known about this new muscle.

Grob et al. (2016) depicts a similar image to the one at right. You can see the three deep aspects of the quadriceps as we previously understood them with the new TVI muscle included (muscle belly is superior to the others’). For reference, this would be a left leg.


> The quadriceps make up the muscles covering the front of your thigh.

deep muscles of thigh> There are four of them (thus “quad”)

  1. Vastus Lateralis (VL)
  2. Vastus Intermedius (VI)
  3. Vastus Medialis (VM)
  4. Rectus Femoris (RF)

> VL, VI, and VM each begin at the upper part of the femur, and travel down the front of the thigh to the patella — your kneecap — where they attach as one big tendon — the quadriceps tendon (image at right).

> The RF begins higher up, attaching to part of the pelvis before travelling on top of the other three muscles until it also reaches the patella as part of the quadriceps tendon.

> The purpose of these muscles is to extend your knee (eg. a kicking motion), control the patella (kneecap), and the RF also helps with hip flexion (eg. high knees)

WHATS NEW? Tensor of the Vastus Intermedius

> The new muscle is called the Tensor of the Vastus Intermedius (TVI).

> The TVI begins at the upper, outer part of the femur, between the VL and VI origins.

> The muscle itself is actually quite short, but it continues down the leg as a thin aponeurosis (basically a tendon) until it also becomes part of the quadriceps tendon and attaches to the patella (specifically the inside, or medial, aspect of the patella). See #1 in the first image at the top of the page for the TVI path.


> The study’s authors suggest a few reasons

  1. This part of the leg is a rare area for surgical intervention, so it is unlikely many surgeons have needed to study this area in GREAT GREAT detail.
  2. The muscle bellies of of VL, VI, and TVI are very close to each other, covered in a complex organization of nerves and blood vessels — so unless a detailed study was required, it could be easily missed
  3. The actual presentation of this muscle changes a bit from person to person — so even if somebody did notice an unusual finding, they are less likely to document and compare it between people

> Yes — sort of.

> While there are references to similar muscle structures in older anatomical studies, and the TVI muscle was found in every specimen (26 legs) examined by this group, the variation between people noted above means your TVI might not be exactly the same as my TVI. In fact, the authors note that the TVI in my right leg could very well be slightly different than the TVI in my left leg!

> Five identified variations

  1. Independent type (42%) where the muscle belly and its tendon (aponeurosis) is unique to itself at all times (no blending with other muscles).
  2. VI-Type (23%) where the TVI tendon shares an aponeurosis with the VI.
  3. VL-Type (19%) where the TVI tendon shares an aponeurosis with the VL.
  4. Common type (15%) where the aponeurosis between the VL, VI, and TVI is indistinguishable — they all share a common one.
  5. Two muscle bellies (19%) where the muscle belly is made up of two or more smaller pieces of muscle instead of one single muscle.

A few reasons lead to the conclusion that this is a unique muscle:

  1. Consistent Origin: Regardless of how the tendon travels, every specimen studied by this group had an identified TVI muscle belly.
  2. Consistent Insertion: Every specimen also had a unique presence in the middle layer of the patellar tendon (where it attaches to the kneecap) — so even with the five variations noted earlier as the TVI passes down the leg, it is always clearly distinguished at the beginning (closer to the hip) and the end (closer to the knee).
  3. Distinct Nerves and Blood Vessels: The TVI is innervated by independent branches of the femoral nerve and is vascularized through unique branches of the lateral circumflex femoral artery. A unique and consistent pattern of nerves and blood vessels should only be present in individual structures.

> Though probably best left to future research on the TVI, the authors do suggest a couple of likely functions:

  1. By way of its basic orientation — travelling down the outside of the thigh from the hip, crossing the quadriceps tendon on a diagonal to reach the inside aspect of the kneecap — it is probable the TVI plays a role in patellar control. That is, it works to balance out the much larger quadriceps muscles found at the inside of the knee, so that the kneecap ultimately moves straight up and down. Or,
  2. As the TVI aponeurosis is often fused or closely related to the VI muscle, it may exert tension on this muscle — contributing to the VI function as well. Hence the name: “tensor of the vastus intermedius”.


IMG_2874Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre — located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000

Primary Reference

Photo Credit Athikhun.suw via Wikimedia Commons — no changes — per CC License.


The Rotator Cuff – What is it?

Shoulder Anatomy

The rotator cuff is a group of four muscles that make up part of your shoulder (see Figure 1). These muscles each attach to the shoulder blade (scapula) at one end, and the top of the arm (humerus) at the other.

Three of these muscles (supraspinatus, infraspinatus, teres minor) are located at the back of the shoulder blade, while just one (subscapularis) attaches to the front of the shoulder blade. This orientation is important because…

Rotator Cuff
Figure 1: The 4 Muscles of the Rotator Cuff
Function of the Rotator Cuff

[…] the rotator cuff’s primary role is to keep the arm centred in the shoulder socket (glenoid cavity). All four muscles act as a unit to pull the arm into the centre of the shoulder socket during movement. Together with the deltoid, this creates a “force couple”, allowing motion to be created by rotation, rather than a change of position (Figure 2)*. This is highly important when we use our arms because the shoulder socket is very shallow — a shallow socket allows a wide range of movement at the shoulder, but does little to prevent dislocations! So without something consistently pulling the arm back to the centre of the shoulder, we would be in big trouble!

rotator cuff or compression cuff?

Consider raising your arms overhead at the side (like making a snow-angel). As your arms leave the side of your body, the four rotator cuff muscles work as a unit, pulling inward towards your centre. Without them, the other muscles at your shoulder (trapezius, deltoid) would draw the arm up and out of the shoulder socket, likely dislocating your arm!

Rotator Cuff compression
Figure 2: A partial example of compression at the shoulder

Why does the rotator cuff matter to me?

Since nearly every movement of the arm requires the rotator cuff muscles to hold things in the middle, many shoulder pains or dysfunctions involve the rotator cuff. If just one of the muscles works too little, too much, or out of sync with the others, the entire unit is jeopardized.

Rotator cuff prevalence
Figure 3: Prevalence of RC tears in one community. Adapted from Minagawa et al. (2013).

Occasionally, this results in damage to the muscle(s). Many people experience “rotator cuff tears”, either partial (a little bit of damage) or full (the whole muscle is torn), requiring treatment to limit pain, increase function, and rehabilitate the shoulder. Usually this is the result of some activity or incident that created the damage — this is a “traumatic” rotator cuff tear. This is probably more common than you might think — in fact,  Minagawa et al. (2013) examined 3000 people (ages 20-90) from a single village, finding full thickness tears in 0-36% of people by decade (Figure 3). So once you reach 50 years of age, at least 1 in 10 people have a full thickness tear.

Conversely, where there is no activity or incident leading to shoulder discomfort, we also must consider “age-related” rotator cuff tears. We see many instances where people experiencing no symptoms at all (“asymptomatic” people) display rotator cuff tears when they are assessed by advanced imaging (ultrasounds, MRIs, etc). The number of these cases appears to go up as a person’s age increases. For example, Tempelhof et al. (1999) examined people over the age of 50 and identified asymptomatic rotator cuff tears in 13-51% of the sample (see Figure 4a). This was supported by the Minagawa study as well, who found 50% of tears in people’s 50s were asymptomatic, and at older ages this increased even more, with asymptomatic tears significantly outnumbered symptomatic tears (>50%) (see Figure 4b).Rotator Cuff tear data

So is having a rotator cuff tear a problem?

That really depends on your individual case. Sometimes rotator cuff tears are asymptomatic — you have no obvious signs of pain, diminished function, or limited activities, and yet a tear is present if you get advanced imaging of the shoulder. Other times tears are symptomatic, causing pain, limiting function, and getting in the way of your activities, and getting treatment to heal, repair, and rehabilitate the shoulder is extremely helpful. Conservative treatments (exercise, manual therapy, etc) have been shown to provide beneficial outcomes for people with symptomatic tears (Ainsworth et al. 2007; Kuhn et al. 2009), so combining interventions like soft tissue therapy, physical modalities, and exercise is often a good place to begin treatment.

In Summary

The rotator cuff is extremely important for typical activities involving the shoulder, providing constant compression which allows our extreme freedom of movement without risking dislocation. However, the rotator cuff is used so frequently in our lives that damage ultimately occurs in a high proportion of the population as we age. Fortunately, this damage does not always create pain or limit function, and when it does manual treatments have good success at resolving the issues.

Dr. Jim Gilliard

Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre — located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000

  • Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. Br J Sports Med. 2007;41(4):200–10.
  • Kuhn JE. Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elb Surg. Journal of Shoulder and Elbow Surgery Board of Trustees; 2009;18(1):138–60.
  • Minagawa H, Yamamoto N, Abe H, Fukuda M, Seki N, Kikuchi K, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop 2013;10(1):8–12.
  • Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296–9.

Carrying Objects – One Hand or Two?

Infographic – Carrying Objects

Carrying Loads

People often wonder what kind of daily activities could impact them long-term — and the simple answer to that type of questions is: all of them. Here is an example of something to that effect. Carrying objects is an extremely common activity. We pick things up, we put them down. We move them across the room, we put them back. In fact, most people have some type of bag (purse, briefcase) that follows them everywhere they go.

What we don’t consider about carrying these objects is how it may impact our long-term health.

Consider the infographic above — the difference between carrying something in one hand, or carrying equal weights in both hands can be significant. In case one, we see the load demanded at the lower back decrease by 44% when 30kg in one hand is changed into 15kg in each hand. So just by balancing the load between each side you can make a great difference for your back. In case two, if you find 30kg to be an unrealistic weight to consider, we find a similar reduction in demands on the lower back by dividing the weight of 10kg between two hands rather than carrying it all in one. This may be more practical to consider, as it closely relates to garbage bags, yard waste, car tires, purses, backpacks, briefcases, etc.

But perhaps the most interesting case is number three. Pick up an object in one hand and you place a certain demand on your lower back — but pick up an equally weighted object in the other hand, so doubling your total object weight, and you actually DECREASE the compression (or loading) of your lower back. In the infographic I reference 30kg again, but in the study cited this finding is true for both 30kg and 10kg (ie. 10kg in your right hand only, vs 10kg in both right and left hands).

So consider for you carry things in your daily life — is it with one hand or two? If you have had a history of lower back pain, or are interested in preventing future occurrences of lower back pain, perhaps making a conscious effort to distribute your (carrying) loads equally is a small step in the right direction.

Dr. Jim Gilliard

Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre— located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000

  1. McGill SM, Marshall L, Andersen J. Low back loads while walking and carrying: comparing the load carried in one hand or in both hands. Ergonomics. 2013;56(2):293–302.

Snow Shovelling

shovelling cartoon

Your least favourite, most Canadian activity

Now that we’ve had (in the GTA) our first significant brush with winter weather, it’s time to reflect and ask the big question: did you miss it?

For most, shovelling snow is nowhere near the top of people’s favourite winter activities, and yet it’s something that almost everybody does. And despite how common shovelling is, few people give it much thought until they’re out there, digging away. A typical story tends to go like this:  a) the snow falls, b) you bundle up, c) you work and work and work and work until it’s done, only to see more snow falling in the freshly shovelled driveway, d) you wake up sore and achy the next day.

snow shovelling
via Flickr – Seattle Municipal Archives

Let’s break this cycle in two ways — by starting to think about shovelling right now, and delivering some simple keys to remember during this common Canadian activity.

1> Choose a light shovel

Your goal is to move snow, so don’t waste your effort on the shovel! As the Canadian Centre for Occupational Health and Safety points out, “[l]oad a shovel (over 1 kg) with 5 kg of snow (just about the average) every 5 seconds, and you move a load of over 70 kg in one minute. Repeat for 15 minutes and you will have shovelled 1,000 kg of snow. Such effort is obviously not for everyone.” So don’t waste that effort on the shovel itself!

2> Use a smaller blade

It might seem counterintuitive to your goal (get the snow shovelled), but a smaller shovel prevents overloading your back – and similar to backpacks, fatigue during snow shovelling may be a good predictor of injury.

3> Push, don’t Throw!

Loading a pile of snow, on a platform held away from your body, attached to a stick will quickly increase the total stress placed on your back. Furthermore, anytime we look to throw something, we usually add at least some twisting motion to make the throwing easier. Big deal? You bet. Now you find yourself bent over, lifting weight, and twisting to throw it — flexion, compression, and rotation of your back — the secret recipe for a disc injury!

shovelling no
This is definitely NOT how I recommend shovelling. via Flickr – Dave Herholz

Other Shovelling Notes

> Many of the same tips for raking leaves apply to snow shovelling as well: warm up first, get ready to work, use two hands, stay close and avoid reaching, and work from both sides.

Left good; Right bad.

> More specific? Use your hips and knees together to move the snow — try not to bend at your back. Generally speaking, you’ll find this to be easier if you keep your body more vertical (upright) during shovelling.

> Ergonomic handles can be good — especially for just pushing snow across the ground — but if you do require any form of lifting they can limit your ability to do so. There are so many varieties out there, sometimes it’s best to try a few and see which is right for you.

> Speaking of ergonomics, some newer devices have gained popularity which are supposed to make shovelling easier — such as The Heft. In theory, adding a lever to the handle of your shovel should absolutely make things easier during shovelling. However, I haven’t personally tried this device, so I really don’t have a position on its effectiveness. My primary concern would be attaching the device too far up the shovel (away from the blade), thinking the location of attachment doesn’t matter. In reality, the closer you attach the device to the blade, the greater your mechanical advantage should be. Food for thought, anyways.

> Snow shovelling often ends up being a form of vigorous exercise, which is good… BUT, if you’re not used to exercising, in poor physical health, or struggle with other health conditions, it is always a good idea to consult a medical professional before beginning a new/vigorous activity. If this is you, perhaps consider seeking the help of family or neighbours in the meantime.

> Finally, remain aware of your surroundings and listen to your body — be alert for frostbite, hypothermia, and fatigue. And of course, know the signs of a heart attack — as the Heart and Stroke Foundation points out, “[w]arning signs can vary from person to person and they may not always be sudden or severe.” Some of the most common symptoms are listed below, but if you are concerned at all about how you are feeling, dial 911 immediately and seek attention:

Signs heart attack shovelling
Warning signs of Heart Attack — Heart and Stroke Foundation

Dr. Jim Gilliard

Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre — located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000

Pt Q’s: Importance of Movement

Q: Why do you keep stressing the need to move around so often? 

Movement Cartilage

Why Movement is Important to Keep your Joints Healthy

Movement is important — or as might be better understood, a lack of movement is potentially harmful. This is the foundation for concepts like “Sitting is the new smoking”, “Motion is Lotion“, and the “Move More Challenge. A lack of movement, commonly termed “sedentary behaviours”, have recently been repeatedly linked to poor health in general (Biswas et al, Ford et al, Martin et al, Santos et al).

But there is one specific part of the body for which movement may be extremely important for:

Your joints.

Joints are covered in cartilage (“articular” cartilage), which provides a smooth, lubricated surface with very little friction, making movements smooth and easy while transmitting the forces of activity (Fox et al). Loss, alteration, or eventual damage to the cartilage changes the ease with which the joints are able to move and function as we would like — think of riding a bike on a freshly paved road (normal joint) and compare that to riding in a gravel parking lot (damaged joint). When we account for other body components that are involved in movements (bones, ligaments, muscles, etc), we begin to understand the important role that cartilage plays in human movement.

However, cartilage is very different that other structures in our body. Unlike many other tissues (eg. muscles, tendons, ligaments, bones, etc), articular cartilage does not receive blood vessels, nerve endings, or lymphatic tissue (Fox et al). Instead, it is primarily made of water, collagen (dense proteins), and proteoglycans (more proteins) — a selected mix that allows your cartilage to promote water retention*. What this means is that your cartilage acts somewhat like a sponge — water flows in and out as pressure changes, and nutritional components move with it — for example, if you load the joint, water squeezes out — and when you unload the joint, new water and nutrients are drawn in.

* To be clear though, considering this fluid “water” is an oversimplification. We would be more accurate to discuss the role of Synovial Fluid, but in the interest of understanding this concept through metaphor, the fluid around your joints is considered ‘water’ for this post.

This is important, because where other body tissues would receive their nutrition from the circulation of blood, monitoring of the nerves, and drainage from the lymphatics, cartilage receives its nutrition from movement. As mentioned above, with water flowing in and out as joints are unloaded and/or loaded, this also delivers nutrition to the cartilage. Without the consistent change in our joints — back and forth, loaded and unloaded — there can be no transfer of water, and therefore poor nutritional delivery to the joints. 

How does this impact most of us? Consider sitting. The joints of the back and hips are loaded when we sit, meaning we slowly squeeze water out from the cartilage in these areas. If we do not get up and move around frequently, this also means there is no opportunity for nutrients to re-enter those joints! This is why movement throughout the day, periodic breaks, and frequently changing positions are so important — it helps to maintain good cartilage health, and prevent future damage.

via Canadian Chiropractic Association (Fit-in-15)

With no actual blood flow to the cartilage of your joints, movement must be its substitute! The cyclic change between loaded and unloaded states are important for our joints to stay healthy into the future. This is a key reason why staying active and promoting movement (avoiding inactivity!) is such an important part of a healthy lifestyle.

Dr. Jim Gilliard

Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre — located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000

  1. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, et al. Sedentary Time and Its Association With Risk for Disease Incidence, Mortality, and Hospitalization in Adults. Ann Intern Med. 2015;162(2):123.
  2. Ford ES, Caspersen CJ. Sedentary behaviour and cardiovascular disease: A review of prospective studies. Int J Epidemiol. 2012;41(5):1338–53.
  3. Martin A, Fitzsimons C, Jepson R, Saunders DH, van der Ploeg HP, Teixeira PJ, et al. Interventions with potential to reduce sedentary time in adults: systematic review and meta-analysis. Br J Sports Med. 2015;49:1056–63.
  4. Santos R, Mota J, Okely AD, Pratt M, Moreira C, Coelho-E-Silva MJ, et al. The independent associations of sedentary behaviour and physical activity on cardiorespiratory fitness. Br J Sports Med. 2014;48:1508–12.
  5. Fox AJS, Bedi A, Rodeo SA. The basic science of articular cartilage: structure, composition, and function. Sports Health. 2009;1(6):461–8.

Happy New Year (Resolution!)

Happy New Year! (2016 already?)

New Year ResolutionIt’s no secret that with the holiday season passed, we are now in the heart of resolution season! I’ve heard a number of people (ironically) resolving not to make resolutions though for a variety of reasons: “they don’t mean anything”, “they don’t work”, “people never achieve their goals”, etc. But just because a task seems daunting doesn’t mean it’s not worth trying. Here is a little information on resolutions, and how you can build successful habits for the new year.

1> Make just ONE resolution — and be specific. Humans are notoriously bad multitaskers — few targets are effectively completed — and as evidenced by Sanbonmatsu et al. (2013), multitasking behaviour has less to do with having many tasks to complete, and more to do with not being able to block out distractions. So cut down the number of things you need to focus on by limiting you resolutions to something specific.

“[…] the findings suggest that people often engage in multi-tasking because they are less able to block out distractions and focus on a singular task.”

2> Be Specific! Starting with small changes to address a big problem can be highly effective. For example, BJ Fogg of Stanford University is a proponent of using Tiny Habits to create long-term change. So instead of saying, “I want to lose weight next year” — why not approach it in a smaller, but constructive way, like “I will no longer visit Starbucks for a mid-morning snack” (sorry Starbucks) — and build from there. This is a specific, small change designed to begin addressing your goal — not solve the problem in a single step.

3> Be on Team You. Our world can feel like a negative, sarcastic, and cruel place at times — but there is just as much positivity out there, too. And positivity, particularly from within, appears to be important for successfully completing a resolution. As Norcross et al. (2002) of the University of Scranton demonstrate, there are characteristic most typical of successful resolvers, and different characteristics typical of unsuccessful resolvers.

For example, successful resolvers spent more time:

  • Staying positive about themselves
  • Believing in their ability to change
  • Believing in their ability to maintain the change long term.

Meanwhile, those unsuccessful spent more time:

  • Blaming themselves for wanting to change
  • Wishing things were different already (in that moment)
  • Thinking about the behaviour you wish to change hurting you.

Use these tips to have a happy, safe, and successful 2016 — whether you tackle a resolution or not!

Wishing you the very best at this time of year — New Years 2016.

Dr. Jim Gilliard

Dr. Jim Gilliard is a chiropractor in Burlington, ON at Endorphins Health and Wellness Centre — located in the Burlington Professional Centre at 3155 Harvester Road, Suite 406. If you have questions, comments, or wish to book an appointment, please feel free to contact him at your convenience.

Phone: (905) 634 – 6000


1> Norcross JC, Mrykalo MS, Blagys MD. Auld Lang Syne: Success Predictors, Change Processes, and Self-Reported Outcomes of New Year’s Resolvers and Nonresolvers. J Clin Psychol. 2002;58(4):397–405.

2> Sanbonmatsu DM, Strayer DL, Medeiros-Ward N, Watson JM. Who Multi-Tasks and Why? Multi-Tasking Ability, Perceived Multi-Tasking Ability, Impulsivity, and Sensation Seeking. PLoS One. 2013;8(1):e54402.