www.srcpt.com/blog

Friends, I appreciate the interest this blog continues to get, but I have moved the blog to my company website and you can find what you are looking for at www.srcpt.com/blog - comments and queries are open there.

Please visit the current blog to get your comments posted and your questions answered. Thanks

Neil

The Blog Has Moved

Friends,

I have relocated my blog to my website. It can now be found here

Please visit my blog there to post questions and search topics.

Thanks

Neil

Postural Headaches

I have seen a number of people recently who suffer postural headaches. In the society we live in where so many people work at a desk in front of a computer monitor, this is not much of a surprise. Computer work leads to a forward head posture that causes mechanical complaints to emanate from the sub-occipital region.

Ideal posture is defined this way:

• The head should rest over the shoulder girdle rather than forward
  
• The shoulder girdle should be depressed and retracted rather than elevated and protracted
• The sub-occipital region should be flexed and relaxed rather than compressed and stressed
• The Sternocleidomastoid muscle should be oriented backward rather than vertical
• The Upper Trapezius should be more vertical rather than horozontal

The causes of postural headaches could be many. For example:

• Trigger points in one or more cervical spine muslces refer pain to the head
• The TMJ might be upset which in turn can cause musculoskeletal headaches as well
• The sub-occipital joints can refer pain to the head
• Entrapment of a sensory nerve in the sub-occipital can refer pain to the head
• Bruxism or grinding of the teeth can refer pain the the head, especially if the Temporalis muscle is irritated by the process.

Postural Correction

The key to reducing your headaches, if they are postural by nature, is to improve your posture. catch yourself with your head out in front of you, and try to retract your head by elevating your chest and bringing your head over your shoulder girdle.

In that position, do very gentle chin tucks repetitively to gently unload the sub-occipital region.

Also, get some aerobic exercise to help the neck muscles relax

My torn Mensicus Two and a Half Weeks Out

So I am a little over two weeks out now, and these past couple of days, my knee seems to have made a sudden improvement with an increase in ROM and reduced swelling. I still can't kneel on the knee, but each day it is getting easier to do ordinary things.

I plan to start rowing again next week since my range is essentially sufficient enough to do that, and because it is an unloaded activity.

The tear I had in the Medial meniscus was more like the radial tear shown in the Lateral Meniscus above. The surgery involved trimming it out and smoothing the remaining meniscus.

Because there was no blood supply or bleeding inside the knee in general, the recovery is fairly quick and there is little opportunity to scar. I do feel the impact of the scar tissue and the fact that the scar tissue is contracting where the arthroscopic tools penetrated the knee during surgery though, especially the scar in my distal Quadriceps muscle - but again, not a big scar and almost a non issue day to day now.

Cervical Nerve Root Compression

Question: How do you know if you have nerver root compression from a herniated cervical disc?

Answer: You have pain AND weakness in the arm .


Click the "play" button to listen:

In the image adjacent, you can see how a cervical spine disc herniation compresses the anterior nerve root of the spinal nerve causing motor weakness. Because the disc is anterior to the spinal cord, and because the anterior nerve root is the motor nerve root, compression leads to weakness and this is always the first consideration when motor weakness is the primary sign along with pain as a symptom.

As in this image, the herniation might or might not be an indication for a cervical discectomy. The reality is that you should allow time to pass before committing to a surgical solution. The reason I say this is that the decision largely depends on what tissue is compressing the nerve root.

If the nucleus is the primary culprit, then allow time to pass because the nucleus is made up of glucosaminoglycans (GAG's) and GAG's decay fairly rapidly, which means that they biind less water. As they decay, they dehydrate, and as they dehydrate, the pressure comes off the nerver root, and strength should return.

On the other hand, if the material pressing against the nerve root is part of the fibrous shell of the disc - the Annulus, then surgery mught in fact be the best option. In this case, the Annulus does not decay, and it is sort of like the reality of having a pin stuck in your arm - it hurts till you take it out. But that said, cervical traction is a good idea to try. If traction is successful, great, if not, the next level of intervention worth trying is potentially selective injection techniques. Often, the combination of selective injections with cervical traction along with aerobic exercise and other gapping activities (to gap the cerival spine, forward bend, side bend the head away from the pain, and GENTLY rotate toward the pain) would offer the best course of action.

Acutely, the position of comfort is to place the same side forearm on the forehead to achieve temporary relief of pain.

So acutely try this:

• Aerobic exercise for a half hour to soften and relax the accessory muscles of respiration
  
• Gapping exercises to relieve the nerve root
• Cervical traction to relieve the pressure
• Forearm on the forehead to unload the tension on the nerve and reduce arm pain
• If all else fails, then see the doc for evaluation and consideration of a selective injection

There are a couple of excellent mechanical home traction units that we use. One, by EMPI, like this one that is recommended.

Depending on which side the herniated disc is affecting, you could position the head in alight side bending to further provide relief while under traction. It is key though, if you use this device, to allow your neck to relax before you pick up your head when you are done with the traction. as for how much traction, I suggest that the traction is pain free, but you should try to use at least 20# of traction for a few minutes when you do use the machine.

Costochondritis/Rib Cage Pain

Occasionally, and typically following trauma, but not always, one can sustain an injury to the juncture between the ribs and the cartilage between the breast bone (the sternum) and the ribs. Alternatively, the irritation can arise between the sternum and the cartilage. I usually see these sorts of injuries after a motor vehicle accident where the seat belt coming across the rib cage creates the injury or when the chest is driven into the steering wheel is the cause. I have one recent case where the irritability was not traumatic at all, but came on after a case of severe and persistent coughing. Patients following open heart surgery often have to deal with this injury.

This is a difficult injury to manage because there is not much blood supply, and it is made more difficult to treat in hitting and throwing athletes because the rib cage needs to be able to rotate forcefully in those situations.

The pain is felt on the outer third of the chest wall, and is seemingly irritated with breathing deeply. Palpation of the joint line can illicit pain. The pain can be bilateral, but is most often unilateral.

The best treatment for this condition is a combination of aerobic exercise, even though it might hurt to breath at first, ice on the irritated chest wall, and a therapeutic dose of NSAID's on board as tolerated. Physical therapy in the form of manual therapy is valuable to oscillate the joints to promote healing, but this is tricky and needs to be done very carefully. Also, mobilizing the thoracic spine through exercise is key. I really like the TRX as a tool here.

The bottom line is that this is an injury that takes a long time to heal, and is easily irritated again, so the return to sport must be managed on a gradient. For example, in the case of a baseball player returning to practice, I would suggest short toss until that was pain free, then gradually working their way to long toss before trying any hitting drills or throwing in form the outfield. As for hitting drills, swing next to a fence until that was pain free before hitting off a tee, before hitting any soft toss pitches, before hitting any regularly pitched balls, before throwing in from the outfield. In the case of tennis for example, ground strokes before overhead strokes and so on.

Peroneal Tendon Subluxation

I recently saw a patient who suffered a ankle severe sprain wake boarding. The sprain recovered, but the ankle continued to "snap". on closer examination, the snapping sensation was actually the peroneal tendon snapping around the lateral malleolus.

You can see how the tendons (in the image to the left) are held in place by connective tissue. When this connective tissue is stretched sufficiently, it will allow the tendons to "snap" over the lateral malleolus. It really is a snapping sensation and it is often painful. You can almost see this snapping in the following two images.

While is it is possible to treat this condition conservatively, in a cast boot for example, when the tendons snap over the ankle repeatedly, then sadly, surgery is the only option. The post surgical course is pretty much the same as it would be for any ankle surgery - the repair has to heal, then the joints and muscles need to be rehabilitated for the athlete to return to their sport.

It is important to repair this injury though, because the peroneal muscles play a very important role in normal foot mechanics. Peronus longus, for example, crosses over the bottom of the foot and inserts at the base of the big toe, while the brevis attaches on the lateral border of the mid foot at the base of the fifth metatarsal. Both plantar flexion, eversion and plantar flexion with eversion are impacted by this injury.

My patient who suffered the injury had a surgical repair and is back on the water without restriction.

SI Joint Related Pain in a 60 yo Male

This was an interesting case that I thought worth mentioning.

In men, the SI joint rarely is the cause of LBP in my experience. In women of course, with a wider pelvis, and the hormone Relaxin softening the ligaments during the first and third trimester, we often see SIJ related pain especially post partum.

I recently saw a 60 year old male patient who had a three month history of pain that was so severe he was unable to tie his shoes or put on his socks. The pain was primarily in his right butt cheek and also in his upper thigh. His physician had ruled out his lumbar spine as the source of his pain. He eventually came to see me when he concluded that he was not getting any better with the passage of time.

His pain occurred when he bent over with his legs wide apart to lift a heavy object. The pain remained essentially unchanged during the past three months in spite of meds and rest.

My suspicion of the SIJ was confirmed by physical exam, and confirmed again when I reduced the subluxed joint.

So the lesson is this:

• Sudden onset unilateral pain in the butt that doesn't seem to get better with time suggests Sacro Iliac Joint pain
• Pain that comes on with an incident, traumatic, lifting or otherwise suggests SIJ pain.
• Pain that meds and rest does not resolve that interferes with weight bearing or hip flexion suggests SIJ pain

Not all back pain is back pain. Not all buttock pain is SIJ pain.

The combination of the history (which raises suspicions) and the physical exam which (confirms or refutes them) is the way to make the diagnosis. BUT, if you have unilateral pain in one butt cheek, AND there is an incident that preceded the pain, THEN you might have SIJ pain even if you are not a post partum female.

The dysfunction is easier to treat in men than women, but it can be treated in women successfully along with a stabilizing belt following the reduction of the subluxation that I wrote about earlier.

Post Meniscus Recovery - one week out

Well, two weeks ago I inured my knee, tearing my meniscus while working out at the track. A week ago I had a minor surgery to repair the torn medial meniscus. All that was needed was a trim of the tor material. With that I should be able to get back to my usual level of activity fairly quickly. I was prompted to have the surgery rather than wait because my knee was unable to straighten and weight bearing was very painful.

The surgery went great, in and out, and at first, while the nerve block was still active, I had very little pain. I went home and put my leg up, my knee on ice. I pretty much had a good day and went to bed thinking all was well.

Then the nerve block wore off! Oh My God..that was painful!!! So with pain meds on board I spent the next 12 hours sleeping.

But I continued to keep off my leg for the next 3 days and treated my knee with ice and electrical stimulation until I went back to work on Tuesday. Even though I iced and stimmed twice during the day, by the end of the day I was tired and sore. By Wednesday though the pain in my quads was quite severe, and my knee was not very happy. This time I used UltraSound on the scars and The Stick on my muscles, and I made it to Friday.

By Friday, one week out, I was no longer limping, but my ROM still had not returned (swelling) and I still have to remind myself to take NSAID's and take it easy.

Today, I will walk a bit, try a bit of rowing, and generally take it easy with my knee on ice.

The most interesting thing that I learned about this post surgical time is that by day 5, the muscles around the knee are really, really tight and sore and really do well with the Ultrasound.

On Thursday, I found myself at the foot of three flights of stairs in a building that has no elevator. That was the most work my knee had done since surgery and I painlessly managed by climbing slowly, although I was muscularly fatigued my knee swelled up a bit after that. I can see how easy it is to over do things. The leg feels like it can do more and I have to consciously restrain myself from moving too quickly, or stepping up or down with my surgical leg.

I am just happy that I was able to get my knee surgically repaired so quickly after I injured it. I am also lucky that the meniscus trimming is a relatively minor procedure because there is very little bleeding, if any, during the procedure, so the recovery is abbreviated.

My torn Medial Meniscus

So I was in training for life, and engaging in a drill where I did various plyometric drills down the track and sprinted back up the track at about 80%.

I did this after a long warm up - a 3 mile jog to the track.

On my 6th repetition, during the plyometric portion of the drill, I was skipping using big arms and gaining a lot of air each skip. After about 30 meters I felt my left knee complain a bit... not too much, but complain nevertheless.

I walked it off and sprinted back making a mental note that I was tired and still had a 3 mile jog ahead of me, so I put it all out there during my last sprint.

25 meters in, my knee went "crunch" and I pulled up with a gimpy left knee. I could not easily bear weight and at first I could not tell what I had done. It felt like my medial meniscus was damaged.

After a few minutes of standing there rubbing my knee, the pain along the medial joint line set in and I limped off home.

On Sunday I had an MRI confirming my suspicions, and tomorrow I go see the surgeon! Ouch. More to follow.

Can I run with Hardware On board?

I got a great question from Vitor about his hardware, the message is:

"Hello,

I had ankle surgery about a year ago following a motorcycle accident, and got a metal plate and some screws (don't know how many exactly). I used to run before the accident and surgery, but I only ran twice recently and stopped because I was afraid I might be doing something that might damage the bone because of screws and plate being there, although I didn't actually feel any pain while running. I've just imagined the screws damaging the bones with the running impact and stopped running. In a month I will have surgery to remove these metal plate and screws. Do you think I should wait until after the plate removal surgery to run?

Thank you very much!"

I responded:

Vitor, this is a really great question. When you have open reduction internal fixation (ORIF) the metal plates and screws serve as "stress risers" in the bone, which means that the bone is having to attenuate more force around the screws than they otherwise would have to if the screws were not there. Ultimately, these stress risers lead to local fractures. Additionally, the plates prevent the bones from flexing, bending and twisting. These are natural actions of the skeleton during the gait cycle especially during running activities which increases the impact loading over walking quite dramatically. The consequence of this is that other stress risers will also develop as the bone responds to the new stresses in new locations, and the result, you guessed it, fractures.

So the long and short of it is this, get the hardware removed, and then allow at least 6 if not 12 weeks to pass before you run again in order the bone to fill the screw holes. ORIF is unfriendly to runners!

Hope this helps,

Neil

The Science of Weight Loss

I have spent a lot of my time thinking about weight loss. My research began several years ago when I found a piece of technology that let us measure metabolic function in the clinic. This tool allows us to identify peak fat metabolism by heart rate, and forms the baseline tool of our in-clinic weight loss program.

The question I asked myself was this: Why do people seem to be unable to lose weight AND keep it off?

The data supported this question with harsh realities such as 8 of 10 people gain 110% of the weight they lose within a year for example.

In reality, it is very simple arithmetic - Eat less and exercise more. But the real questions are how much less? And how much more?

The premise of my research argues for simplicity in weight loss. We know that you can lose weight by going on a diet, and we know that you need to exercise to keep it off (the national weight loss registry supports this assertion even though the number of people who have lost more than 50# and kept it off for more than 5 years is very few.)

But I felt that there was something missing, and in my research, I believe I found the answer!

Ready? Type II muscle selectively atrophies.

This fact is made even more important because Type II muscle is preferential in fat metabolism.

Type II muscle is only produced when MAXIMAL effort is expended. I'll rephrase that, in order to build Type II muscle, you have to exercise at maximal effort because if you do not, you only build Type I muscle. On the other hand, if you do exercise at maximal effort, then you actually build both Type I and Type II muscle.

So my conclusion is that in order to lose weight you need to go on a diet (I believe that a Paleo Diet makes the most sense - i.e. fresh fruit and vegetables along with lean sources of animal protein), AND in order to keep it off, you need to exercise at maximal intensity to stimulate production of Type II muscle.

But in the middle, while eating well (nourishing foods), there is value to sub-maximal exercise that takes advantage of the peak fat metabolism HR data we gather by measuring metabolic output.

For example, I have measured in myself that if I exercise at 140 b/m, I burn 8 Kcal of fat per minute, compared to 130 b/m where I only burn 3 Kcal of fat per minute. So if I row (on the ERG) for an hour at 140 b/m, I have burned 480 Kcal of FAT! And because I sprint for 30 seconds every 10 minutes and for the last minute of my training time, I make Type II muscle, which leads to ongoing fat loss at rest while my body first replenishes the used muscle glycogen, and then runs at a higher RPM (more muscle on board means a higher resting metabolism).

One other consideration is muscle based glycogen. A good hard workout burns up muscle based glycogen as well as liver and heart based glycogen. Post exercise recovery involves replenishing this resource. Regular exercise means that you deplete and replenish in an ongoing manner leading to a revved up metabolism. Since you can only replenish at a defined rate between 5% and 10% an hour depending on your fitness, daily submaximal exercise with intervals to stimulate Type II muscle metabolism leads to this cycle in the most efficient manner.

Weight loss occurs intramuscularly first, then intra-abdominally second and finally sub-cutaneously last. When it does start to occur sub-cutaneously, then it starts at the top of your head and works its way down...so be patient, persistent, disciplined, and consistent.

Eat less and exercise more..now you know!

Neil

Ramping Up Training

This time of year, I see my triathlon patients showing up in the clinic with overuse injuries.

Because it is early season and the weather is getting nicer, there is a tendency to ramp up training too fast. My suggestion is pretty simple really, instead of increasing miles in your run, say, try to double up sports, do a bike ride before your run. That way you increase your aerobic training, but reduce the pounding . As the season progresses, you can increase your mileage output in your run, bike or swim, but to avoid injury, try doubling up sports.

Remember, the best way to deal with a sports injury is to avoid one altogether!

High Ankle Sprain

Typical ankle sprains are sprains of the anterior talo fibular ligament. The high ankle sprain also involves the syndesmosis between the tibia and fibula as well. The big difference is that while the ATF ligament sprain does well with early mobilization, the high ankle sprain needs to be stabilized in a cast boot for three to six weeks. Failure to do so almost ensures arthritis long term. Once out of the boot, the rehab is about the same as for any ankle sprain.

You should progress from balance to balance challenges to loading (lunging and elevation changes) , to impact loading (jumping and hopping) to running with cutting, stop/start and turning.

Acutely, RICE therapy is appropriate, but weight bearing should be in a cast boot for the best outcome. Its best to wear the cast boot for at least 6 weeks to allow the tissue to heal to a sufficiently strong repair.

Remember at 3 weeks, the scar will be present, but weak, only 15% of its final integrity. At 6 weeks, the scar will be 42% of its final integrity. At six weeks, 42% strong, the scar can tolerate much more loading than at any time earlier.

Better safe than sorry. A high ankle sprain in a cast boot means back on the field with little or no residual long term effects. To early back to the field of competition, and you are risking a chronically irritated ankle with arthritis developing over time.

Chronic Neck Pain Revisited

Earlier, I wrote a blog about chronic neck pain after an accident. I want to make a few more points about managing chronic neck pain that I think are worthwhile.

• Less is more: The structures of the cervical spine are small. Look at your little fingernail. That is the size, more or less, of the facet joints in the cervical spine. Imagine how much force you put your shoulder through and compare the size of the joints! So the "less is more" idea speaks to doing only a few exercises at a time. I like to limit the reps to 6 (yep, six), and also suggest 6 times a day.
• Move into the pain: Unlike the lower back, it makes a lot of sense in the neck to move into the direction of the pain. If it hurts on the right and you avoid right rotation for example, you will quickly find that you cannot turn right.
  
• Heat or Ice? I mostly say that ice is the ticket, but for some reason, heat around the neck will help the muscles relax more. Remember this: Heat only helps WHILE it is on, take it off and the muscles tighten right up.
  
• Posture, posture, posture: Try to get your head over your shoulder girdle. It makes all the difference.
• Fit or fat? It turns out that aerobic exercise stimulates the accessory muscles of respiration. This will help your neck settle down. 30 minutes a day every day.

Hope this helps,

Neil

Femoral Stress Fracture

I have had several patients over the past couple of years that have sustained femoral stress fractures while running. The presentation is not always the same because the fractures happen in different places along the femur. In each case, the patient was referred to me by another medical practitioner for physical therapy to treat their non-specific leg pain. In each case, the pain mimicked muscle pain and only a careful history teased out the possibility that a stress fracture was hiding under the radar.

• First of all, I can say that almost without fail, the fracture occurred as the running intensity was elevated. The patient did not notice the pain immediately, but noticed it soon after, in each case by the next day.

• Second, the pain was exacerbated with running, and specifically elevated with impact (landing on the injured leg).

• Third, no matter what stretches the patient employed, if they used ice or not, the pain did not diminish.

• Fourth, taking meds, like NSAIDs, did not resolve the pain.

• Fifth, a complete orthopedic evaluation ruled out all the muscles as a source of the pain.

A suspicion of a stress fracture needs to be further investigated by a bone scan which shows a 2% change in bone density rather than an x-ray which illustrates a fracture when there is a 50% change in bone density. Some physicians prefer an MRI to rule it out, but most opt for a bone scan.

The treatment for a stress fracture is the same as for any fracture. Non-weight bearing for 6 weeks, followed by 6 weeks of rehab before returning to previous mileages.

My Love Affair with the Concept 2 ERG continued!

Coming off a long layoff after a rough motor vehicle accident 3 and a half years ago, I started to work on increasing my fitness on the Concept 2 Erg...see the earlier post. Well the first 2K I rowed, my VO2Max was recorded at 14 ml O2/kg/m....this is really low fitness for sure since the scale is 15-70! What V02Max determines is ones level of aerobic capacity measuring how much oxygen can me transported to and used in the working muscles during exercise.

10 weeks later, my VO2Max is recorded to be 41 ml O2/kg/m, which is above average...the concept 2 website has a great calculator that considers your age and weight and best 2K time to calculate the number.

So in 10 weeks I have gone from horribly low off the scale fitness to above average fitness on about 33,000 m of hard rowing per week (5 days a week).

I am excited about this beyond that as well since I am losing weight and firming up. I have lost inches from my waistline and I am on the road back to my fighting weight!

That's it for now!

Neil

The Way Back From Runners Knee

Turn your volume up and click "Play":




One of the most common injuries I see is often referred to as "Runners Knee". This is really anterior knee pain that commonly afflicts runners, but could be caused by several different tissues. Most commonly, the condition reflects lateral tracking patella and patella femoral pain. In point of fact, most people I see are also suffering patella tendinitis in addition the pain caused by the loading of the patella against the femur. I consider the combination of these two to be a more accurate reflection of the diagnosis "runners knee".

Runners develop these complaints largely because of their biomechanics. Not to put too fine a point on it, but structure governs function. What this means is that the architecture of the knee is ultimately determined by the architecture of the foot on one hand and the hip on the other.

Since our feet sprout from the trunk sole up in utero, and later in development rotate to assume the position that allows us to ambulate in a bipedal fashion, we end up with a foot that is either partially rotated (supinated) or one that has simply rotated too far (pronated).

So in the end, since the knee, which is a simple joint, follows the tibia in space and since the tibia follows the talus, and since the talus follows the calcaneus, the position of the calcaneus at the time the foot hits the ground and its subsequent motion ultimately determines where the knee ends up in space.

This is important because the foot has two jobs in life: It is either a mobile adapter (as it swings through space during the swing phase of the gait cycle) or it is a rigid lever (as it prepares to propel us forward off the ground). It is the transition between these two end points that is interesting to me.

It turns out that if the foot is pronated or supinated, the knee will probably end up too medially, which will put pressure on the patella to located itself more laterally and this will indeed lead to excessive patella femoral contact and possibly pain. The stress on the patella tendon here will also likely cause irritation in the tendon as well.

The shape of the pelvis and the location of the femoral neck on the femor will also play a roll, with the wider hips of women being to blame for the more severe "Q-angle" at the knee in women, again a factor in lateral tracking patella.

OK, so you have runners knee and want to know the way back.

First, you need to use ice. I advocate ice plus water in a plastic bag on the knee for 30 minutes,
either that, or an ice popsicle (freeze a paper cup filled with water) and rub that over the knee for 10-15 minutes. It is sometimes easier to use the ice popsicle, and sometimes easier to use the plastic bag. If your pain is largely in the tendon, then the ice massage technique works better. To get the cold to penetrate so that the patella femoral irritation is reduced, then the ice bacg seems to be a better strategy.

You also need to stretch the quad and ITB if they are tight, and you need to use the stick or foam roller to massage and elongate those tissues.

For patella tendinitis, you need to do the following: Take a dinner spoon or fork, and place the long neck of the implement against the tendon. Press firmly into the tendon and rub back and forth to resolve any irritation in the tendon. It is often quite painful at first, but over a few days this technique seems to reduce the irritation significantly.

Don't forget that this is really a biomechanical problem at its root, and so you need a biomechanical solution - i.e. Custom Orthotic Therapy. You need to get fit with custom made orthotics, especially if you find yourself wanting to walk or stand on the outside of your feet (implying an uncompensated forefoot varus). You can read more about orthotics in an earlier post.

From a long term intervention perspective, you need to take a joint supplement if you don't already. I also posted about joint supplements earlier.

And of course, there is no substitute for common sense. You can do things like avoid down hill running, avoid hard surfaces (concrete, pavement and blacktop), moderate your distances and of course make sure your shoes are in good repair.Make sure to return to running on a gradient...ie do not run too fast, too far or too early.

Lower Back Instability

Turn your speakers on and click "play" to listen

Much is said about the core. Almost everybody is offering "Core Stability Programs" now. So what gives? First one should understand the etiology of core instability:

1. Tight Hamstrings: In our modern world, we sit all day and our hamstrings are allowed to gradually shorten. If you are a runner, you never really stretch out your legs, so your hamstring is not stretched to its full length then either. Same with cycling. So what? Well tight hamstrings limit the mobility of the pelvis during activities such as bending and lifting, which in turn, requires that the lumbar spine take up the slack. Over time, this shift of motion responsibility to the lumbar spine will have the effect of increasing the mobility in one or two motion segments of the spine. (A motion segment is a disc plus the vertebra attached above and below.) The bottom line is that tight hamstrings are a causative factor to the unstable motion segment of the lower lumbar spine.

2. Weak Abdominals: Our sedentary lifestyle again is responsible for the chronic weakness in our abdominals. There is a "stretch weakness" that exists as well with the abdominals being inhibited by the tight hip flexors and lower back muscles. This is referred to as a "lower cross syndrome". Tightness of hip flexors, coupled with weakness of the abdominals, especially the lower abs reduces the capacity of the trunk to successfully" stabilize" the lower back.

3. Progressive Failure of the Disc: Over time, as we age, it is very common for the disc itself to fail. Failure of the disc over time for several reasons including mechanical wear and tear, leads to excessive "play" in the motion segment making segmental instability a very real problem in many people. Coupled with tight hamstrings, weak abdominals and tight hip flexors, the unstable segment is put under more duress during motion, and as such bears the load of bending and lifting that should rightfully be borne by other structures.

4. Restricted Thoracic Spine: The T-spine is naturally restricted and over time becomes even more restricted resulting in reduced backward bending ROM and reduced ROM into rotation. The loss of this ROM leads to an increased demand for movement in the lower lumbar spine as well as the cervical spine.

When you put all this together with the fact that we have become a sedentary population, over weight and out of shape it is no surprise that the spine breaks down and structures in the spine fail.

Add to that one more fact:

5. Deep Muscle Inhibition: Pain the back is coupled with deep paraspinal muscle guarding, which in turn produces prolonged inhibition of those same muscles through a neurological mechanism. This gradual weakening of the deepest muscles adjacent to the spine are the final "nail in the coffin" of the unstable segment.

OK, so what about core stability exercises, do they work?

In short, the answer is "yes". What core exercises do is stabilize the spinal column by squeezing the organs against the front of the spine and wrap the the trunk in a casement of muscle that is rock hard front and back. The idea is to provide support to the spine through positive pressure that prevents the spine from collapsing or moving excessively under load.

Complementary to the core stability exercises, another key is to strengthen the deep spinal muscles, such as multifidus, in order to provide local stability on a segmental level.

So to summarize, in order to improve athletic performance, reduce segmental back pain, stabilize the lower back and the core, you need to do a good solid core program. I will elaborate on that in a later post.

Long Standing Sacro Iliac Joint Pain

Turn up your computers volume and click the play button:




One of the things I see in people who suffer long standing SI joint dysfunction is the "reluctance" of the Si joint to remain stable once the dysfunction has been reduced. It seems that almost regardless of the subluxation (up slip, down slip, anterior torsion, posterior torsion etc), the joint wants to "return" to the subluxed position.

To help stabilize the joint after reducing a subluxation, I employ two strategies that are muscular and one that is not.

The nature of the SI joint is that there are no muscles that cross the Si joint that are useful for stabilization purposes. The Piriformis originates on the inside of the Sacrum and should be perfect for stabilization purposes, but because it inserts on the Greater Trochanter of the femur, it is useless for stabilizing the SI joint.

Instead, we have to look forward to the Adductors which insert onthe inferior pubic ramus and also the Abdominals which insert on the pubis. These muscles are better suited to maintain the stability of the pubic symphesis and indirectly, the SI joint.
Try these two exercises to stabilize the SI joint:

• Sit on the edge of a firm chair, lean over, your knees apart, and put your elbow on the inside of one knee and your hand onthe inside of the other. Squeeze as hard as you can while also at the same time trying to be as relaxed as you can. Repeat this about 8 or 10 times. You are looking or a palpable click to occur in the groin indicating that the pubic symphesis has reduced. this does not always occur though, so if it does not occur, not to worry.

• Lie on your back, both knees flexed up toward your chest. Place a hand on either thigh near the knees and push as hard as you can with both the knees and hands so that you do not let your thighs actually move. You should feel your stomach muscles working hard.

The other stabiliation idea is to use an external fixation, like an SI Stabilization Belt. I like one you can purchase here. It is caled the BOA Sacro-Iliac Belt. Be sure to size it properly, and when you wear it, keep it snug. Also, as an alternative this one is also a good suggestion.

The thing about reducing an SI Jointsubluxation is that after I have sucecssfully reduced the joint, it often wants to return to its former subluxed state, and after each successive reduction, it often takes longer and longer sublux again. My advice is to be very patient. Allow weeks to successfully treat the joint so that it stays reduced. And while you are undergoing treatment, use the belt and do the exercises I suggested for longer lasting relief.

Finally, I think that you should use ice religeously. By that I mean 30 -45 minutes of ice plus water (not those blue ice packs that you throw inthe freezer, not frozen corn or peas, actual ice) right on the skin. Make sure to include water, or risk frost bite.

My Stiff Neck

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People often experiences a stiff neck with or without headache. sometimes this stiffness can last for weeks. There are a few things I suggest that seem to be effective dealing with this problem. But we need to start with the anatomy.

Think of the cervical spine as a mobile column with a bowling ball held on top. remember, your head weighs about 10% of your body weight. The "wires" that hold the head onto the neck are muscles, the Levator Scapula (picture on the left) and the SCM, (picture below). The levator is the muscle most widely thought to be associated with a stiff neck.

In a prefect world, the position of the head over the neck would be in an erect posture with the neck more or less straight up above the shoulder girdle.

Think of a helium balloon, the balloon hovers in the air the string straight up and down. In order for the head to be in a similar position above the shoulder girdle, the guy-wire muscles Levator Scapula and the Sternocleidomastoid will occupy positions in space that give them mechanical leverage.

Gravity works though, and as a result, posture is often poor with a forward head that puts the guy wire muscles of the cervical spine at a mechanical disadvantage. The result is that they have to work harder to hold the head up. Their increased effort leads to increased compression of the joints of the spine. The result is muscles that are over working and accumulating metabolic by products that are irritating to them, joints that are continuously compressed causing irritation of the structures in and around them, and a physical body that is easily fatigued and inefficient in movement patterns and strategies.

The result can be an acquired stiff neck with headaches or without. Sometimes the neck joints can be irritated enough or have accumulated enough destruction to actually irritate the nerves that feed the arm causing pain, numbness, tingling or weakness into the arm or hand as well.

For the purposes of this blog, I am going to focus on only the postural stiff neck with no radicular symptoms.

To reduce your stiff neck, try this:

1. Catch yourself with a forward head position, and bring your head back over your shoulder girdle (think about that balloon floating on top of the string, and make your head do the same on top of you neck).
2. Do 30 minutes of aerobic exercise to get the accessory muscle of respiration (your neck muscles) to actively contract and relax for ong periods of time submaximally so that they can relax.
3. Put a rolled up towel behind the neck, pull it over your shoulders to the front, grab with both hands and pull the towel down toward your feet. Then let your head bend backwards and when all the way back gently rotate left and right. PAIN FREE>
4. If it hurts to turn left, then practice turning into the pain by turning left repeatedly. Do so gently, and just knock on the door of the pain, don't move through the painful range.
5. Remember, the neck joints and structures are very small. You don't need to move too far or work too hard to actually be very helpful to the neck. I like to say about the neck that "Less is More".
   
   Try these techniques to resolve your local neck pain without any radicular symptoms of pain or numbness or weakness.

To Stretch or Not to Stretch?

There is a lot of mythology in circulation regarding stretching.

The resting tone of a muscle is established neurologically. What that means is that organelles in the muscle called the muscle spindle, which controls the quick stretch mechanism of the muscle, determines the sensitivity to stretch of the muscle, and it also seems to be involved in establishing the resting tension in the muscle. So in a nutshell, that means that stretching does not seem to impact the resting length of the muscle.

So why stretch?

Well, I can think of a few reasons to stretch. First of all, when it comes to competing, a little pre-competition stretching has been shown to improve performance. The reason for this is surmised to be that the actin and myosin relationships in the muscle are optimized allowing the muscle to work more efficiently. And clearly you see top athletes stretching before and after competing for sure. What is current practice in competitive athletes today is what is known as an "active warm up", which is made up of little movement patterns that are part of the full motion package that the athlete will engage in. I also know, though, that top teams spend a lot of time stretching to prevent injury in professional soccer players for instance. So there is still uncertainty.

I also believe that when one stretches, one is taking the joints through a more complete range of motion, which will have a positive impact on the articular cartilage. Cartilage requires intermittent compression plus gliding to be properly nourished, and stretching might get you to take your joints through a full ROM without overloading them.

Additionally, the same idea is true for your dense connective tissues - the ligaments and capsules get maximally stretched when the joint achieves maximum congruence, which occurs at the end of the range of motion of a joint. So at the end of the joints ROM, the cartilage is maximally compressed and the ligaments and capsules are maximally stretched, all of which helps prepare the tissue for activity. I imagine that the dense connective tissues imbibe water as they relax after being maximally stretched for a few seconds, and it is that process that "protects" them from overuse injury during activity.

Stretching also activates both joint receptors and muscle receptors in areas being stretched that are inhibitory to the muscle and relax it for the moment. Does this relaxed muscle stay relaxed? I don't believe so. I believe that muscles get longer if you "play them longer". What I mean by this is that if you use a muscle in a longer range, say by following through while kicking a football for example, then your muscle will gradually tolerate a longer resting length. Muscles are very elastic. If I cut your biceps tendon at the elbow, I could take the end of the muscle and walk across the room with it, more or less, and if I let go of the end I was holding, the muscle would recover its resting length.

"What about yoga?" I hear you asking...Well in yoga, you don't just stretch, you activate the muscles in longer ranges which is why people who practice yoga actually become more flexible. But they also increase the flexibility of their joints, and their muscles are encouraged to be active through longer ranges, hence appear to be longer because of stretching.

Whats the bottom line, to stretch or not to stretch?


I think that stretching is a valuable practice to engage in for injury prevention purposes in active people. Stretching helps prepare the muscles,tendons, and the joint dense connective tissues including the cartilage be prepared for loading. I do not think that stretching makes you more flexible in your muscles per se though. So yes, before and after exercise, stretch. In Anderson and Anderson's classic book, Stretching, there is a great 10 minute daily total body stretching routine. In my mind, that's all one really needs to do as a routine stretching practice.

Beyond that, it is really up to you, and if you do more and feel better for it, by all means go ahead.

If you intend to stretch, it pays to warm up a bit before you do so. I suggest a 5 to 10 minute warm up before you stop and stretch, then you will be ready to compete, you joints and other dense connective tissues lubricated and hydrated, your muscles prepped for activity, and your brain in the mindset for competition.

Managing Acute Back Pain

I wrote an article for the Journal Orthopedic Clinics of North America a few years ago with my colleague Mike Kane, PT a physio in Yakima, WA. The premise was Functional Rehabilitation Strategies of the Lower Back. In that article I laid out the full picture, and also talked about acute lower back pain (LBP). Since 80% of people suffer lower back pain, and a third of them in the last 24 hours, I thought that I would share my successful strategy for dealing with acute back pain in greater detail.

First of all, realize that most episodes of lower back pain are self limiting. Very often, the pain will resolve within a few days, and 8 out of 10 times, within a month, 9 out of 10 times within 2 months.

Because we are not very good at diagnosing LBP (something like 15% of the time is a diagnosis determined to be accurate), the underlying cause is not really important in dealing with acute LBP.

The literature strongly suggests that a person suffering LBP should not curtail their activities. If you are a runner, keep running, a walker, keep walking, a swimmer, keep swimming.

But lets say you experience a severe episode of LBP with or without pain into the leg, you should know this: It is a medical emergency if you actually lose control of your bladder. If that happens, go to the ER immediately. You only have a limited amount of time to address this problem or you face the permanent loss of bladder control.

In the alternative, here is my fail safe almost 100% successful acute LBP treatment strategy:



1. Start out lying on your back on the floor in the 90/90 position with your legs up on a chair. Stay in this position for about a minute focusing on your breathing. Try to relax as you do so. The reason that this position is useful is that in this posture, the intra-discal pressure is the lowest it can be, and that usually means less pain.


2. In this position, start by dragging your right foot along the chair as you bring your knee toward your chest. Use your hip flexors and abdominal muscles to bring your knee up to your chest as far as you can. Try to move as quickly as you can PAIN FREE. When you achieve the maximum ROM, then push your foot back along the chair and repeat the move with your left leg. Repeat this activity back and forth 30 times with each leg. Remember, move as quickly as you can as far as you can, but drag rather than lift your leg.

3. The next exercise involves you bringing both legs up at the same time. Make sure to spread your knees apart as you do so in order to clear your pelvis. Again try to really curl up by engaging the lower abdominal muscles. Repeat 30 times. Be sure to drag your feet rather than lift them, and make sure the movement is as rapid as possible, but again, PAIN FREE.

4. The next exercise is desigend to engage the trunk in a rotational movement pattern. Wrap both arms around your chest and pick your head up. Keeping your butt on the ground, roll onto your right shoulder, then onto the left shoulder. Repeat 30 times in each direction as quickly as possible, PAIN FREE.

5. OPTIONAL. This exercise I make optional for people. The activity is in sidelying, but you have to roll up a blanket and put it under your ribs. Push it up to the arm pit to reduce the ROM, or further down to increase the ROM. Place the up arm on top of the body, and grab the top shoulder with the bottom arm. Perform 10 reps of side lifts PAIN FREE. Roll over, reposition the blanket and repeat on the other side.

Perform all these exercises 3 times through - it will take about 20 minutes.

The final exerise is key. You need to do this exericse at the conclusion of your previous exericses and again every hour throughout the day, or whenever you LBP irritates you.

6. Half sit on a table with your feet firmly planted on the floor shoulder width apart, your arms wrapped tightly around your chest, one arm above the other. Maintain an erect spine posture, but lean slightly forward at the waist. The exercise is a 5 minute drill of left and right rotation only. The key, as you might already guess, is to move as quickly as possible, PAIN FREE. Gradually increase the ROM as you do the exercise and can tolerate more motion.

Franky, this last exercise is almost magical. Almost everybody with very few exections will benefit from the exercise.

Finally, you need to use ice to inhibit the muscle guarding. In our clinic we have found that crushed ice plus a little water in a plastic bag right on the skin for 30 -40 minutes is the best solution. The reason this is important is that it takes 10 minutes for the ice to penetrate 1cm (about a half inch), and the muscles that are guarding live about 3 cm deep. So prolonged ice inhibits the pain, decreases muscle guarding and reduces edema that might be present.

Add to that 30 minutes of walking and you have a very very very effective acute LBP management program. We call this program Phase 1 LBP Managment.

Good luck

Return to Running after a Lateral Ankle Injury

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Shin Splints

Shin Splints most often are correctly named Medial Tibial Stress Syndrome and occasionally Posterior Tibial Tendinitis. In our clinic, we typically see Medial Tibial Stress Syndrome in active runners and soccer players. The beginning of cross country season and the beginning of track season are the times we typically see this complaint.

Usually, the onset correlates to early training with overuse occurring such that there is shin pain associated with running. Deconditioned people who start training, active people who increase their mileage, lengthen their stride, or start doing jumping drills, or runners who start running further on hard surfaces or down hills are all susceptible to MTTS. The worry is that the leg pain might be a stress fracture or even a compartment syndrome.

Typically, the pain associated with compartment syndrome is early onset and lasting, and seems out of proportion to the amount of effort expended. Compartment syndrome is ultimately diagnosed with Doppler technology, and if you think you have shin splints that do not seem to get better at all ever, then it might be that you have a compartment syndrome and you should get that checked out. The other concern, stress fracture, can usually be ruled out by trying to hop on the injured leg. If you cannot do so, and the pain persists, then you might indeed have a stress fracture. in the case of MTSS, the pain usually resolves quickly after activity.

The best treatment for MTSS is to stop running for a time, PLUS perform ice massage along the injured area, PLUS improve your shoes, PLUS modify the surfaces you are runing on, PLUS use tape or a shin strap when you do return to running.

One good exercise to help you is to sit in a chair with your elbows on your thighs, and while keeping your heels on the floor, rapidly tap your feet one after the other until you are too tired to do more. Allow a time to recover, and repeat.

Return to running gradually and perferably on flat softer surfaces with new shoes. Build your mielage gradually, improve your speed gradually and you will likely overcome this ailment without difficulty.

Fat Metabolism in English

OK, so you want to loose weight. And you are wondering how to go about this in a sane and safe way that is guaranteed to be successful according to scientific principles.

Very simply it is an arithmetic problem. Calories in minus calories out equals calories lost or gained. In order to lose 1# a week, you need to unbalance your metabolism by 500 cal per day. In other words, you need to burn 500 more calories than you take in.

Easier said than done.

So you need to manage both sides of the equation. Eat less and exercise more. How much less and how much more is an interesting question. In our clinic we use Smart Metabolism technology to measure your metabolism, and then we calculate both what you should consider your baseline metabolism, and we calculate your peak fat metabolism heart rate during exercise. Combining this data, we can calculate what you need to do to create that 500 calorie differential.

But lets say you don't really know how to do this, or do not have access to this technology where you are, here is some advice:

• You need to generally eat less than you probably are. Serving sizes here are out of proportion. One way to eat fewer calories is to get a lot of calories from fruits and vegetables rather than empty calories like those found in rice and potatoes. I am a HUGE fan of The Paleo Diet which professes to eat more lean animal protein, and only fruit and vegetables as well as a few nuts. This is a diet program that is not like going on a diet at all. It is more of a change in eating habits to eating only really nourishing food until you are really full.

On the exercise side, there are a couple of considerations:

• Sub maximal exercise, sometimes called aerobic exercise, burns fat. But you need to exercise for a long time since the output is sub maximal in order to burn fat in a meaningful way.
• Interval training from your sub maximal zone to higher heart rates approaching your max heart rate and then recovering to your submaximal heart rate accelerates the process of fat metabolism
• Short bout high intensity exercise (like sprinting) builds your fast twitch muscles (type II) which themselves are preferential in fat metabolism.

What that means is that when you have type II muscle on board, you find it easier to break down stored fat to use as energy. Remember, fat is the primary fuel.

A fit Olympic class athlete THINKS about exercising and starts to metabolize fat (ie turn triglycerides into fatty acids. Fatty acids are fast moving fats that race around the body looking for a muscle to burn them, while triglycerides are usually parked or stored fat. If a fatty acid does not get burned while racing around the body after being released, it can easily be stored again - head fat today, butt fat tomorrow.)

An active person needs to exercise for 5-15 minutes to start to burn fat efficiently. An unfit person will exercise until their sugar stores run out and then sit down again, never burning fat.

We have found in our clinical research that it takes 30 minutes of daily exercise at peak fat metabolism heart rates to stimulate normal fat metabolism mechanics. We have also found that interval training accelerates the fat metabolism on a minute by minute basis (ie more fat calories burned each minute). And we have found that the introduction of short bout high intensity exercise significantly increases calorie out put. In fact in a study we conducted with one person, she burned an extra 1000 cal per day by increasing her output by 6 one minute intervals per day.

Understanding a little more about glycogen use and replenishment will clear up the picture further.

Glycogen is resident in the muscles. We use stored glycogen to operate a muscle. we use fatty acids to help in the process of replenishing glycogen during and after exercise. During sub maximal exercise we use glycogen up and replenish it during exercise and while we use glycogen during max output exercise, we do not replenish it until after exercise in the case of high intensity exercise.

In replenishing glycogen store, we are not exactly sure of the mechanism, but heart muscle replenishes first, and once it is fully restored, then the skeletal muscle replenishes its stores and then once the skeletal muscle is fully recovered, then the liver finally gets its stores replenished. After exercise, a fit person replenishes at the rate of 10% per hour, and an unfit person at the rate of 5% an hour. For this reason, if you are just starting out, then make sure to take a rest day in order to replenish fully. You can also influence your rate of glycogen replenishment because in the first 30-60 minutes after exercise, you can replenish more quickly if you take in sugar (the only time it is OK to do that!)

So to lose weight you need to exercise more an eat less. How much more and how much less can be worked out, and we will be glad to help you figure this out exactly in our clinic. But if you are going to go it alone, then make sure to eat regular healthy meals that have a high protein content (lean animal meats) and low glycemic index carbs (lots of fruit and vegetables), and to exercise both submaximally for 30 minutes a day and also perform interval training while exercising submaximally. And then on top of that add several shourt bouts of high intensity exercise to ensure continued increased metabolism during your recovery after exercise.

And finally, what is "metabolism"? Metabolism is the sum total of energy of all the chemical reactions in your body. to increase your metabolsim, you need to increase the number of chemical reactions in your body. Since we are not very efficient animals, sweating, a response to exercise induced heat, represents an increase in metabolism. In the end, exercise is the best medicine.

Hope this helps!

Neil

My New Love Affair With the Concept 2 ERG

For a little over a month, I have been ERGing...indoor rowing (see the previous blog to see the device).

It has been great to feel my body getting stronger and to watch the quantifiable evidence of that. For instance, during the first week, while I was just getting started, in fact during my first row, I was able to complete 1500m at a pace of 3:21 per 500.

Today, I completed 6000m at a pace of 2:15 per 500. That is four times further, with each 1500 occurring more than 3 minutes faster than I was able to do on day one! This is also a big difference because on the ERG there is a cube effect that means that to improve by 10%, you need to increase your output by 30%. Wow!

I am on the ERG Monday through Friday, and I am trying to complete over 30,000m per week.

I am doing:

• 6000m on Monday and Thursday
• 2x 2000 m on Tuesday
• 500 m on Wednesday with a 2000m cool down
• 10,000 m on Friday

With the warm up I do, I should be able to make my goal each week. Of course, I am complimenting the ERG with a kettlebell routine that really makes me tired and strengthens my legs and shoulders further.

The best news is that I am sleeping great, eating better, feeling fitter and losing weight! Perfect.

Just thought I would share!

Neil

Sleep Apnea

This is a new idea for me.

My wife pointed out to me that I sometimes gasped for air during the night. so out of curiosity, I scheduled a sleep study at a local sleep diagnostic center. It was quite an ordeal. 26 electrodes attached to my head, chest, legs finger etc caused me to believe that I would not be able to sleep at all. But in spite of being wired like a guinea pig, I managed to fall asleep and what a surprise!

I learned that I suffer about 14 episodes per hour of sleep apnea where I literally stop breathing for up to 10 seconds! In addition, I learned that I get very little REM Sleep, and the REM sleep I get is very disturbed , and I learned that my blood oxygen saturation levels drop from 95% saturation to 85% saturation.

This probably explains the HUGE cup of coffee I tend to drink in the mornings and my tendency to be a "slow starter" only becoming fully awake by 10:00 am. I can honestly say that for about the last 10 years, I have felt like taking a nap every day.

The following week, I went back to the sleep diagnostic center and repeated the test, but this time with a CPAP (continuous positive air pressure) device, and to my complete amazement, the sleep apnea was cured, the snoring silent, the oxygen saturation level normalized, the breathing regulated and the REM sleep deep and prolonged, completely normal. The result, I am a completely different human being, rested, alert, and able to exercise with greater intensity duration and output. According to my calculations, I demonstrated a 6% increase in my output during exercise the first week.

I learned that 60% of adults suffer sleep apnea, that it can be dangerous (stroke or heart attack are possible) and that it is potentially is a marriage saver since my snoring has literally completely stopped. Wow!

If you wake up tired, feel like you need a nap every day, suffer from snoring, or if you are observed gasping for air at night, check it out...this could be really important for you.

Suggestions for Home Gym

Lets say you have under $1000 and you want a full home gym that will keep you totally fit, a big-bang-for-your-buck gym so to speak.

In framing my thoughts I am thinking of tools that allow you to exercise aerobically and anaerobically to build your aerobic conditioning, to perform power training, strength training and core training.

Tool number 1: The Kettle Bell Figure $75 max
For men the 35# kettle bell, for women, the 20# or 25# kettle bell.

The range of exercises you can do with this tool impact your overall strength of legs, shoulders and core profoundly.



Tool number 2: The TRX Allow $200 max

• This exercise is wonderful for core strength and offers several excellent upper body and lower body isolation activities.

Tool number 3: A 40# punching bag - Allow $150 to get the bag, the gloves and the tools to hang it.

You can do any number of punching drills - it is an excellent tool to help generate rotational power.

Tool number 4: The X-iser Stepper - Allow $400
This wonderful tool allow you to perform short bout high intensity exercise as well as core, hamstrings, gluts, shoulders, and calf muscles. This is an excellent tool that emphasizes short bout high intensity exercise for type two muscle development



Finally, tool number 5: The Concept 2 ERG - Allow $900
I include this because it is a great inexpensive total body tool that allows wonderful fitness development. Matching this with a kettle bell for instance, will give you an outstanding home gym.



Ultimately, the best exercise there is is the one you actually do. But these are the best tools I have found for overall body conditioning that are both effective and efficient as well as inexpensive.


Neil

Hip Pain Due To Trochanteric Bursitis

I am often treating distance runners with complaints of hip pain that leads to an active Trochanteric Bursitis.

First the anatomy: The bursae live under the Iliotibial band and over the Greater Trochanter. You can see in the illustration that the Gluteal muscles insert into the hip and iliotibial band. The role of the Bursae is to act as a lubricator for motion of the ITB (iliotibial band) over the boney prominence of the hip so that there is no deterioration of the ITB during motion.

The ITB is the cause of bursitis in my opinion. Typically, a shortened ITB increases the stress of the bursae and with repetitive tasks, like distance running, the bursae can become inflamed. This is what is referred to as Trochanteric Bursitis.

The Iliotibial Band Syndrome is a companion to Trochanteric Bursitis, and we often see them hand in glove. While ITB syndrome typicall causes pain in the ITB and at the knee, a tight ITB leads to increased pressure on the bursa and often causes it to become inflamed.

..
It is easy to see the relationship between the hip and the ITB in this illustration which demonstrates the typical sight of pain at the knee in the case of ITB syndrome.

But even if you do not have a true ITB syndrome, you most probably have a tight ITB that causes excessive friction over the bursae leading to trochanteric bursitis.

We treat the bursitis as follows:

• Ultrasound over the bursae to increase circulation around the bursae
• Occasionally, with a prescription we might employ phonophoresis or iontophoresis - both cortisone delivery mechanisms - to help reduce inflammation.
  
• Ultrasound over the tightened spots of the ITB to soften the ITB
• Myofascial release therapy over the ITB using one of our tools like The Stick for instance. The Stick is also very useful at home. See my earlier blog on the use of The Stick to understand how best to use it
• Ice and Electrical Stim over the bursae to reduce edema and pain
• Orthotics to improve the biomechanics
• Kinesio Tape to lift the skin up over the bursae
• Stretching of the ITB
• Strengthening of the Gluteal muscles
• Introduction of cross training strategies for distance runners (running, cycling an swimming are all unidirectional activities - you need to introduce true cross training - ie lateral and rotational activities.
• We also encourage outpatients to take NSAID's as prescribed - but at least at a therapeutic dose - and to discuss this with their doc if the dose prescribed is less than a therapeutic anti inflammatory dose
  

One consideration for runners is that the knee does not really straighten while running, so flexibility of the hamstrings and of the ITB are important to pay attention to in order to avoid both ITB Syndrome and Trochanteric Bursitis.

You can read more about biomechanics on our website

Recurrent Lower Back Pain

I am often asked about why mechanical lower back pain is recurrent. I have four related explanations that I think have validity. These are:

• The first is the tension between mobility and stability
• The second is the fact that muscle guarding leads to atrophy
• The third is mechanical with respect to disc behavior
• The fourth is deconditioning

Mobility vs Stability
The premise is that we stand on a stable foot with an ankle that moves, we have a stable knee and a hip that moves, our lumbo/pelvic region should be stable, our thoracic spine mobile, our shoulder girdle stable, our cervical spine mobile.

If you accept that premise, then the logical conclusion is that restriction somewhere leads to mobility somewhere else. A restricted hip, for example, can lead to lumbar break down as greater stresses are transferred to the structures of the lower back, especially the discs, during such activities as forward bending. Segmental hypermobility (excessive mobility in one motion segment) is very destructive to the soft tissues, especially the disc.

To treat the mobility/stability dysfunction, a good assessment needs to be followed up with a personalized exercise program to lengthen shortened tissues and strengthen weakened tissues. A good hamstring lengthening program will go a long way to decrease excessive forces across the lumbar spine.

Muscle Guarding
The deep para-spinal muscles such as Multifidus for example, are muscles that guard when the back causes one pain. The guarding, a localized tightness can extend as many as 5 levels up and 5 levels down in the lumbar spine. This is not a problem on its own, but the fact that guarding leads to atrophy of those same muscles, and the atrophy is a precursor to mechanical lower back pain especially in a segment that is hypermobile. The weakenss of the atrophied para-spinal muscles allows the component motion of sheer to occur which in turn causes local nerves to complain and pain to be experienced. Strengthening the para-spinal mucles is key to resolving segmental dysfunction. Muscle guarding and segmental dysfunction go hand in hand.

Mechanical Factors
The lumbar disc has an axis of rotation that is close to the front of the disc. This means that the posterior lateral corners of the disc are actually subjected to the greatest stress during rotation. This gradually leads to failure of the posterior lateral fibers of the disc and eventual disc herniation. Paying attnetion to one mechanical functions - ike facing what you are doing, avoiding combining bending with twisting and lfiting, avoiding prolonged static postures and so on is the best medicine.

Deconditioning
The simplest way to say this is that very few fit people have recurring mechanical lower back pain.

There it is. Much of this is then in your control. You can get in better shape , with special attention being paind to restrition and weakened areas (like the hamstrings on one hand and the core on the other), and the spinal rotators as well. And you can avoid lifting things that are awkward to lift, or use really goo dmechanics when you do sit around or have to do serious lifting.

Finally, don't forget to use ice....30 minutes of ice (ice and water in a plastic bag right on the skin) is a great way to manage pain long term. You will get up to two hours of relief, and possibly even eliminate pain altogether.