Thoughts of an Experienced Sports Physical Therapist

www.srcpt.com/blog

2009-09-22T07:59:00.000-07:00

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

2009-07-15T08:13:00.000-07:00

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

2009-07-08T10:31:00.000-07:00

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

2009-06-09T10:54:00.000-07:00

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

2009-06-08T09:40:00.001-07:00

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

2009-06-06T09:51:00.000-07:00

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

2009-06-03T07:08:00.001-07:00

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

2009-05-30T11:37:00.000-07:00

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

2009-05-30T10:57:00.001-07:00

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

2009-05-19T22:50:00.000-07:00

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?

2009-05-19T07:34:00.001-07:00

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

2009-04-25T09:48:00.000-07:00

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

2009-04-21T08:09:00.000-07:00

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

2009-04-07T11:28:00.000-07:00

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

2009-03-31T21:16:00.001-07:00

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

2009-03-29T19:00:00.001-07:00

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!

2009-03-22T14:43:00.000-07:00

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

2009-03-08T12:44:00.000-07:00

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

2009-02-26T10:28:00.001-08:00

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

2009-02-20T11:30:00.000-08:00

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

2009-02-17T07:40:00.000-08:00

Turn up your computer volume and click the play button:

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:

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).
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.
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>
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.
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?

2009-02-15T15:12:00.000-08:00

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

2009-02-14T09:30:00.000-08:00

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

2009-02-12T18:36:00.000-08:00

Turn up your computer volume and click the play button:

Shin Splints

2009-02-09T08:32:00.000-08:00

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

2009-02-05T22:07:00.000-08:00

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

2009-02-02T22:32:00.000-08:00

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

2009-01-29T17:58:00.000-08:00

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

2009-01-27T15:32:00.001-08:00

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

2009-01-24T12:22:00.000-08:00

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

2009-01-20T16:35:00.001-08:00

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.

Congratulations President Obama!

2009-01-20T12:30:00.000-08:00

The BIG Picture

2009-01-18T20:26:00.000-08:00

Friends, I write this post to share with you something I am really excited about. I believe that we need to help each other as much as we can. I believe we need to do this on a global scale, and we need to do it now. Especially with the economy in such crisis. I watched the Obama Inauguration Kick Off today, and was again moved by our amazing capacity to reboot as a nation. Coming from South Africa as I do, I can share with you that around the world, people are watching and longing for a successful Obama Presidency, and an American economic recovery. Our fiscal health impacts everybody.

Well I am a huge fan of Micro Banking, first described by Professor Muhammad Yunus in his book Banker to the Poor, and I set as a goal to participate in micro banking as a contributor, fund raiser, lender as best as I could in my lifetime. I had hoped that once I retired from PT I would be able to help people, especially in the third world, self actualize. But with the world wide economy so dire, I felt that I needed to act now.

Well I recently discovered KIVA.org - an amazing organization that allows a person to donate $25.00 and once it is re-payed, loan it again and again and again indefinitely. KIVA has a process of bringing together viable entrepreneurs with potential lenders and in a few short years, KIVA has grown from 7 loans on their website to over $50,000,000 successfully loaned out, to now, with one loan a second being made, and over 16,752 lenders made a loan this week alone.

I am inviting you to join KIVA.org, and to make a small contribution to see how it works. If you are like some of my friends, you will find it an amazing way to contribute directly to someone in need with no overhead to speak of, all your contribution reaches the intended person. You can set up teams, like my team here. Or you can join a team (you are welcome to join my team if you like), or you can donate as an individual.

Please consider joining KIVA.org, make loans to people you select in the part of the world you select, at the rate of lending you select, and help a person achieve a happier life. In my humble opinion, doing so will help you feel good as well.

Thanks,

Neil

Why 6 Weeks to Return to Sport?

2009-01-16T08:54:00.001-08:00

In a word, scar tissue formation.

Interestingly, the way the body deals with an injury is by forming scar tissue. We repair, and we do so with remarkable alacrity. The process of the scar both becoming stable and tolerant of tensile stress is pre-determined. Assuming everything goes well, there are very specific time lines.

Between 0 and 4 days, there is no prepair per se', just bleeding
Between 4 days and 15 days the construction of the "scaffolding of repair" takes place. This scaffolding is not tolerant of tension, but it gradually picks up strength
By day 21, the scar achieves 15 percent of its final tensile strength. This is good because at three weeks loading is important to help organize the scar and make it as strong as possible - more of this later.
By day 42, six weeks, the scar achieves about 40% of its final integrity, and there is much that one can do on a scar like that has achieved this level of tolerance without irritating the injury.
And by day 90, the scar achieves 90# of its final integrity.

The process that the scar undergoes, building of a scar from the initial injury, is significantly impacted by the introduction of tension. The reason for this is that the cells that build scar, fibroblasts, have a pole like the earth has a pole, and with intermittent tension, the cells align themselves parallel to the lines of stress, and the scar tissue fibers they lay down are also placed parrallell to the lines of stress. This leads to a stronger and healthier scar that is tolerant of stress as those fibers bond with adjacent fibers.

Why Use a Stick

2009-01-14T09:36:00.001-08:00

The Stick is a wonderful tool that we use here in the clinic almost every day and on almost every patient. we actually sell them here, but you can also buy them at their website too.

We use The Stick two ways:
- To smooth out dense connective tissue thickenings and
- to treat "trigger points" in the muscle.

Trigger points were first identified by Janet Travell, MD, President Kennedy's physician. These are microscopic areas of inflammation in the muscle tissue that lead to local muscle fiber contraction. Trigger points are palpable, painful and they interfere with normal muscle function. The Stick is used to treat these trigger points in a "seek and destroy" fashion. Yes its painful! The key is to find the trigger point, press hard and maintain the pressure as long as you can to let the trigger point resolve. You should find an immediate increase in flexibility of the muscle. Allow a day or two to pass before you do it again.

The other way we use The Stick is to "brush" the dense connective tissue. we do this by rolling gently, but deep enough to affect change in the way the tissue feels. It is not so much a trigger point level of pressure, but rather the rolling can be a before or an after exercise activity. My athletic patients who use the stick find this to be a very worthwhile process.

My theory is that the benefit of The Stick accrues because local dense connective tissue trauma produces local dense connective tissue scarring. That local scarring produces a local thickening of the tissue, that in turn interferes with normal function, ie elasticity, of the tissue. Using The Stick over time leads to a softening of those local scars, and allows the normalization of the elastic properties of the dense connective tissues. In turn, muscles can cantract and develop tension normally, and the overall function of the part improves perceptibly.

There you have it.

Again, if you would like a Stick, we carry a couple of them for sale.

Whats your "Real Age"?

2009-01-13T18:03:00.000-08:00

Each year about this time, I wonder what my real age is - as opposed to my chronological age. I saw a banner ad on the internet today that said "Barack Obama's real age is 42, Whats yours?" and it reminded me of the website Real Age.

I am 49, and after checking my data, the website concluded that my real age is 44.8 - Not bad, but I am on a mission to improve my health status and get my real age down even lower. The website reminded me to take my vitamins, and hang our with friends. I also noted that pets reduce your real age (could it be the unconditional love?) as does exercise and diet.

My exercise program at the moment is basically heavy weights plus interval training five days a week and one day a week of a long walk (2 hours) with my wife and dog, one day off.

Why interval training? Because the data is crystal clear on this point. Short bout high intensity training is significantly more effective at lipolysis (breaking down stored fat), it improves plasma glutamine, increases Human Growth Hormone levels, and increases Type II muscle mass- the power fibers.

In two short weeks I have noticed that I sleep better, I am leaner, I eat with more consciousness, and my stress levels are reduced. On the whole, I feel better so far.

If you have questions about your exercise program, feel free to drop me a line. In the meantime, check out Real Age and find out how you can improve your health status.

How Aggressive Should Physical Therapy Be?

2009-01-03T15:27:00.000-08:00

Muscles need to be pushed to grow and become healthy. One overlying principle that there is in my world view is that Type II muscle selectively atrophies. Another way to say that is "use it or lose it". The reason a 40 year old man looks so different than an 18 year old is that the 18 year old engages in activities that stimulate the production of Type II muscle (fast twitch fibers) whereas the 40 year old typically engages in activities that are more endurance oriented, and which only stimulate Type I muscles, the endurance fibers. Another aspect to this consideration is that Type I fibers adapt to exercise levels, implying that at a steady state, the Type I fibers no longer mature and grow.

In a nutshell, what this means to me is that first of all, for rehabilitation to be complete, both Type I and Type II muscles need to be stimulated. So exercise needs to include short bout high intensity activities for that specific purpose.

Now that said, given that I believe that PT is a three tier process, Phase 1. Get you out of trouble, Phase 2. Make you strong and durable, and Phase 3. Make you bulletproof, the short bout high intensity component of the rehabilitation process is best timed to coincide with late Phase 2 and all of Phase 3 activities. In fact we use the ability of a patient to execute short bout high intensity activities to signify the end of their rehabilitation and the start of their return to training. In the case of athletes, they can return to practice at this point, and still yet increase their match fitness to be able to return to competition safely.

We keep statistics in our office, and our data shows us that our average number of visits in our center is 9 per patient. We see people 2x per week, and so we usually see people for about 6 weeks, more or less. Now this is just an average and of course we see people longer and more often if the situation calls for it. For example, our Work Conditioning Program participants are in our facility daily for 6-8 weeks, and we often see athletes who need just one or two visits. But if you figure that we see people over about an 8 week period, it is in that time frame that we move from Phase 1 to Phase 3, and if that is to be the case, then PT needs to be aggressive.

This means that as a patient you would need to work pretty hard to resolve your issues in that short time frame.

That means we have to have you working on restoring your foundational movement patterns, building your functional (especially core) strength, and rebuilding your lost Type II muscle mass in that brief period of time.

The only way that happens in that time frame is with sweat and post exercise muscle soreness. Post exercise muscle soreness in this case is NOT pain (ie, irritated joints, tendons, discs etc).

In the event that you are interested in reading more, you can visit our website where I go into more detail about PT at Sports Reaction Center.

The Hip Flexor Mechanism

2008-12-24T15:53:00.000-08:00

The hip flexors that get hurt most often are those closest to the surfaces. For example, in athletes we often see the so-called "Hip Pointer" injury. This is really a hip flexor mechanism injury at the proximal insertion of the muscles at the ASIS (the anterior superior iliac spine) - that boney prominence on the front of the hip. Deeper than that are the true hip flexors, Psoas and Iliacus with a common tendon on
the femur Iliopsoas. Because of the proximal insertion of the Psoas on the lumbar spine, people with sway back (a very lordotic standing posture, seem to be more susceptible to hip flexor trouble, especially if active. The reason for this is that a sway back leads to the hip flexor being effectively shortened, and the iliopsoas more susceptible to strain. The anterior pelvic tilt that accompanies a sway back is associated with lower back pain as well.

Manual therapy for shortened iliopsoas includes a myofacial release technique that can be quite painful, and an active/passive manual stretching procedure. For acute injury, I use an extra long ace bandage to support the hip flexors (we call this a spika wrap), and we use ice, occasionally ultrasound and also electrical stimulation to help get us through the acute phase. I also use the Stick to treat the tight muscles of the thigh including the ITB and the Quad mechanism. In the event that you have tightness of the ITB and Quadaceps mechanism, then using a Stick or similar tool at home will help you resolve those restrictions. In any event, the long term key is to first stretching the hip flexors effectively, and then to strengthen them as they gain length.

Three stretches I really like include:
1. Standing: Leg flexed with your foot behind you up on a table, knees aligned to the center, stomach contracted to flatten the back, shoulders upright and then flex the knee of the foot you are standing on. You should feel the stretch in the front of the quad. To increase the stretch, stand further away from the table so you have to reach further back.

2. Half Kneeling: The knee of the hip you want to stretch is on the ground. Your body is upright. Contract the stomach muscles to keep the lower back flat. Bring your weight forward onto the front foot but keep your shoulders upright until you feel the stretch in the groin. Take your same side hand and reach over the top of your head and leaning your body gently over to the side.

3. Prone: Lying face down, arms spread out, bend your knee of the leg you want to stretch. Again, tighten your stomach muscles to keep your back relatively flat. Pick up your knee and try to reach over your body and touch the opposite hand with your foot.

A word about stretching: First of all, stretching SHOULD NOT HURT. Second, you need to hold the stretch for at least 30 seconds. Third, to improve the effectiveness of the stretch, try contracting and relaxing the muscle you want to stretch.

Do muscles get longer when you stretch them? In a word, "no". The length of a muscle is established neurologically. So why stretch? A fair question. What you are doing is helping the dense connective tissue become hydrated and also "resetting" the relationship between the actin and myoisin components of the muscle fiber. This helps the muscle, in either case, be more tolerant of stretching during activity. In other words, you can be active without the hip flexors experiencing failure.

For strengthening, I like these two exercises:
1. Supine: Lie on your back with your foot on top of one of those big Swiss Balls. Loop an elastic cord over the top of your foot, so that it is pulling downwards (along the line of your leg, parallel to the floor). Bend the knee and pull the toes up to keep the rubber band on the foot until your hip flexors get tired.

2. Sprinting up a hill: Like it says, sprint up a really steep hill over and over. Focus on high knees. This makes you flex the hip to prevent catching your toe. This is very a effective exercise. we usually work up to 10 10 second repeats with a 20 second rest break between sprints. If you amke sure to lift your knees, this exercise will make a big difference.

When I Turn My Head I Get Pain in My Arm

2008-12-18T12:49:00.000-08:00

In the neck we think of anterior column and posterior column issues. The anterior column is typified by the intervertebral disc, while the posterior column is typified by the facet joints. When you have pain that is not accompanied by weakness, then the pain is not likely to be caused by a bulging disc. Pain associated with weakness or weakness without pain implies that the disc is at fault. This is because in the cervical spine, the spinal nerve roots are distinctly motor nerve or sensory nerve roots. The anterior nerver roots are motor nerves and therefore are more likely to be impacted by a disc bulge or herniation, while the posterior nerve roots are sensory nerves in which case several factors might irritate them.

You can see in this illustration the difference between a disc herniation causing nerve root compression and a normal cervical relationship. Nerve root compression can involve sensory AND motor nerve compression, although it is possible to have pure motor nerve compression. In contrast, posterior column disorders typically produce only sensory changes. These could take the form of increased or decreased sensation as well as pain. Absent sensation implies a nerve root compression, while anything less than that suggests a nerve root irritation.

Got all that?

OK so you turn your head to the left and you feel a loss of sensation and pain in your arm and hand. You do not feel weakness, and you do not feel any numbness. When you turn your head away, it feels better. When you backward bend your head, it feels worse, forward bending feels better. Assuming all else is normal, this picture would lead me to believe that you have a posterior column problem with an irritated nerve root.

If I am correct, and again, I assume that you have had your health checked by your doc, you don't feel sick or nauseated and you are otherwise healthy - then you probably have an irritated facet joint at least. In any event, we need to provide a gaping drill to help you unload the structure.

Here is how you unload the RIGHT SIDE posterior column: Start by sitting on your right hand. Then

1. Forward bend your head to a natural stop.

2. Side bend your head to the left side until you encounter a natural stop

3. GENTLY rotate your head to the RIGHT again and again and again PAIN FREE

This should reduce your pain and give you relief by gaping and unloading the right side facet jionts.

Achilles Tendonitis Rupture?

2008-12-14T22:16:00.000-08:00

The Achilles Tendon often ruptures somewhere around age 40 - I usually see this injury in men, but as Misty May, the US Beach Vollyball Star learned, women experience this injury as well.

The Achilles tendon, like all tendons, is a dense connective tissue made up of microfibrils of collagen, the most prevalent protein in the animal kingdom. As we age, little by little, the tendon fails microfiber by microfiber, and while this is not a serious issue on a microfiber level, at a certain point, the number of microfibers that have failed starts to interfere with the function of the tendon, usually felt as stiffness in the tendon.

When the tendon reaches a level of weakness that it starts to feel poorly, the tendinitis, there is usually already irreversible damage to the tendon with sufficient microfiber failure that leaves the tendon vulnerable to further damage and eventual rupture.

When the tendon ruptures, it often sounds like a gunshot and feels like you have been kicked on the back of the leg. I often hear stories about the person going down and looking back to see who kicked them, only to find that there is nobody there. The tendon usually ruptures when the foot is placed on the ground while moving backwards, when you plant the foot for example.

The best thing to do to avoid a rupture, and even Achilles tendinitis, is to a. stretch regularly, and b. Strengthen the muscles of the calf, and c. avoid overuse of the tissue if you can help it.

As far as strengthening and stretching are concerned, you need to remember that there are two muscles that could in fact be stretched and also strengthened. The Gastrocs and the Soleus. The Gastrocs cross the knee and the Soleus does not, so in strengthening the Gastrocs for instance, you need to keep the knee straight, while on the other hand, strengthening or stretching the Soleus, you need to keep the knee bent. I believe that most acute strains of the Gastrocs affect eh medial third of the muscle, but most ruptures of the tendon are caused by lack of stretching of the Soleus especially. So give attention to this muscle and I think that a lot of trouble can be avoided.

As for strengthening, my suggestion is that you work up to 40 continuous heel raises off a step so that the heel drops down, with both a bent leg and also a straight leg to ensure strong muscles.

As far as overuse is concerned, this is especially an issue for runners who allow their shoes to deteriorate excessively while putting on the miles, and also for basketball and tennis players, for some reason, who step backwards a lot. I think a good strengthening and stretching program will eliminate most trouble.

One thing to think about is that if you have had a lot of pain and or stiffness in the Achilles tendon over the years, you are at risk for rupture, especially if you can actually feel the tendon get a lot thinner as you palpate along its length. In that case, I suggest you perhaps avoid activities like basketball or tennis, and treat the tendon to reduce inflammation as much as possible.

Holiday Post

2008-12-10T21:02:00.000-08:00

This post is more of a free rant. If you will, consider just how fortunate we are. We are in the midst of the worst financial crisis since, some say, the civil war, some say the great depression. And because we live in the Pacific Northwest, we are late to "the party" (some party).

In any event, between the Feds, the stock market, and the media, I see things beginning to turn, so I want to reach out and promote that each of us consider making a contribution to somebody MUCH less fortunate.

In order to stimulate that idea, I have found this website, Kiva.org that is a micro lending site, that in a great way, leverages the power of the internet to connect people who need help with people willing to give help.

If you are reading this post, please make a contribution here.

I am committed to micro lending. It is a truly great way to help again and again and again. The evidence supporting micro lending is overwhelming. This is the very best way to help women in the third world self actualize.

Merry Christmas to you - Happy Hanukkah too. Whatever you celebrate this holiday season, I hope that you will be safe, healthy, and find yourself prosperous next year!

Happy New Year.

Neil

My Foot Still Hurts After Months, What Gives??

2008-12-08T10:00:00.000-08:00

Plantar Fasciitis causes really painful feet, especially in the bottom of the foot near the heel. I agree that it can be difficult to treat, and so I am going to share my "secrets".

First of all, lets establish that you actually have plantar fasciitis:
- You experience persistent pain under the foot that is worse in the morning, worse with every step.
- If you press near the heel under the foot, it HURTS
- You do better with heavy boots, or at least with stiff soled shoes
- You have had only marginal relief with NSAID's

OK, so this is how I treat this injury:
1. Ice massage every day.
2. Night Splint every night
3. Small steps in the morning
4. Low Dye tape protection
5. Ultrasound in physical therapy
6 Discontinue activity temporarily
7. After the injury calms down (about three weeks) then start stretching and strengthening
8. Custom orthotic therapy
9. Gradual return to loaded activities.

This is an example of a Plantar Fascia night splint. Some are more elaborate than others, but this one is a good one.

Lets say you try the above and it STILL does not seem better, then I have my ace in the hole....Crutches. Yep, you have to go non-weight bearing for 6 weeks, and also do all the items above as well. Honestly, I have helped hundreds of people recover from persistent Plantar Fascia inflammation using this strategy.

Rotator Cuff Tear or Tendonitis

2008-12-06T08:57:00.000-08:00

The rotator cuff tendons, especially Supraspinatus, is one of those spots in the body that is set up to fail. Why you ask? Well the tendon is located in a "watershed" area between two bones, the head of the Humerus below and the Acromion above with not great blood supply. Every time the arm is elevated, the blood supply is further impacted by the Humerus pinching against the Acromian. In people who have a "down sloping" Acromion, the pressure arrives on the tendon earlier than usual, and over time the tendon weakens in the area with poor blood supply, and the tendon can tear when loaded. I have seen so many people with surprising stories about how they ended up tearing the Supraspinatis tendon, from being pulled behind a boat while water skiing on one hand to playing basketball and catching an arm while shooting on the other.

A tear in the RC Cuff can be full thickness or partial thickness. A partial thickness tear can produce some shoulder pain, usually out on the lateral side of the shoulder, and it can "hide" being mostly pain free, or produce an achy shoulder from time to time. I had a partial thickness tear in my left shoulder from an gymnastics injury in high school when I was 17 years old, and it came and went for years until I tore it again playing basketball when I was 38 years old. At that point the tear was deep enough to bother me all the time, and especially at night. Night time shoulder pain is one of those "red flags" that implies that further testing is appropriate. If you are having hard time lifting things, opening your car door, and coping with unexpected movements, its time to see you doctor!

The good news is that an accromioplasty (shaving the underside of the acromion) and a rotator cuff repair (shaving off the torn part) is a quick recovery, but the full thickness tear is more work. Here is a good full thickness surgery repair blog

Even after the full thickness repair, a full recovery is completely possible...you can read more about recovering from injuries on my website here.

The Wacky SacroIliac Joint

2008-12-04T21:40:00.000-08:00

The Sacro Iliac joint is complex for sure. Besides having to axis of motion and a weird shaped joint surface, there are two of them, all the muscles that cross it have more than one joint that they control, the symmetry or lack of symmetry between the joints add a degree of complexity as well, and the entire weight of the upper body is transfered through the SI joints to the lower extremities.

This is an x-ray of the SI joints looking down on the middle of the joints from the top:

I will say this: We see many more problems with women than men with respect to the SI joint. The reasons for this are first, the wide pelvis and the shallower SI joint angles, second, the impact of hormones on ligament laxity, and third, the consequence of pregnancy (change in weight bearing loads and angles combined with ligament laxity). We usually see SI joint problems in people who were not recently pregnant after trauma of some sort. For example, runners who land in a hole or shallow spot unexpectedly, or people involved in a sudden breaking event or head on impact in a car for example. My point is that absent pregnancy it is rare to see a true SI joint instability. On the other hand, we do see restrictions of SI joint mobility that do have consequences at the hips and lower back for example.

How do you know if your SI joint is irritated? Well, if there is a true hypermobile SI joint that is symptomatic, you will most likely have unilateral pain in your buttock. In the event that the joints are simply hypomobile, then it is harder to determine on your own, and a good evaluation will reveal the restriction. Unfortunately, the symptoms that the irritated SI joint usually cause are also symptoms of other typical issues like lower back pain of discogenic origin, and a good physical evaluation is key to sorting out your symptoms.

The real challenge in treating the SI joint is not so much the hypomobile structure, because it is relatively easy to get a stuck joint moving again, but rather, the challenge is to stabilize the hypermobile joint. The reason for this, I alluded to earlier, and that is that every muscle that crosses the SI joint also crosses or controls another joint. For example, the Piriformis muscle is the major muscle that crosses the joint close to the joint line. But while the Piriformis muscle inserts on the inside of the Sacrum, it also inserts on the femur crossing the hip once it exits the pelvis crossing the SI joint.

You can see how intimately the Piriformis muscle relates to both the SI joint and the hip and the adjacent hip muscles as well as the Sciatic Nerve.

So what do you need to do if you think you have an SI joint problem? First of all, use ice over the gluteal muscles. It seems to make a big difference. Second, get a good evaluation because the maneuvers that you need to make to figure this out need someone specialized to test and observe. Third, (and this depends on the evaluation) you will either need stabilizing exercises or mobilizing exercises. Finally, footwear might play a roll (Excessive pronation or supination will lead to stress across the SI Joint.) If you need stabilization though, an SI joint belt might be of service. This is often hit or miss though, but definitely worth a try.

My best advice is to get a good mechanical evaluation by a physiatrist, a physical therapist or a chiropractor, because that will determine the specific treatment strategy you need.

That Crazy Pain in My Shoulder!!

2008-12-04T21:15:00.001-08:00

Today, a 45 year old baseball pitcher described a pain in his shoulder that only hurt when he crossed his arms and pressed his fist into the back of his arm, pushing his arm forward causing local pain in the front of the shoulder more or less. He also described getting grossly fatigued while pitching, losing both velocity and staying power. The pain came on originally after he pitched through an illness.

Physical exam was insignificant. Rotator cuff screens were negative as was the AC joint screen. Palpation unable to reproduce symptoms. Muscle test negative. Neuro negative. Joint play negative. The only positive symptom occurred with him reproducing the anterior glide of the humeral head on the glenoid using his other hand behind the involved right arm.

My conclusion is that he tore his Glenoid Labrum. We will find out for sure after he has an MRI or surgery if the surgeon decides to go that way.

The Labrum seats around the Gelnoid Fossa to make it effectively deeper for the Humerous to seat properly. When the Labrum tears, it can tear on the top (a SLAP lesion) or on the bottom (a Bankart lesion). You can see the proximity of the biceps lesion to the superior tear in the Labrum, and for this reason, many SLAP lesions actually also involve the Biceps Tendon.

In the event that you actually have a torn Glenoid Labrum in either form, the SLAP lesion or the Bankart tear, I am afraid that the best option is surgical. The good news is that recovery is excellent. The last patient I treated who had surgery for this condition, had both the SLAP and the Bankart lesion, and he went on to a full recovery after surgery by playing college football just a few months later.

Rehab for the post surgical course is not very complex, it just takes hard work. Starting with immobilization, then self mobilization activities, to full ARROM to strengthening to dynamic strengthening and throwing ultimately.

Its a long road back for sure, but the route back to full participation is certain. "Bulletproof" shoulders are possible after surgical repair.

Lets talk about Core Stability

2008-12-04T10:11:00.000-08:00

"Why should I do core exercise?" is the most common question I field for people suffering lower back pain.

First, the anatomy - segmental instability occurs because a motion segment (vertebra - disc - vertebra) allows a component motion of sheer which is not anatomic. In other words the vertebra above should never sheer against the vertebra below. This abnormal motion would occur when a disc has lost its volume and therefore its height. we see this as a narrowing of the disc space on x-ray. Once sheer is allowed, it is safe to assume that the static stability of the spine is lost.

In this image you can see the loss of disc height.

Muscularly, there is an opportunity to stabilize the spine dynamically using the muscles that surround the core. In front and on the sides are the Rectus Abdominus, the Internal and External Oblique muscles and the Transverse Abdominus as well. In addition there is the strong lateral stabilizer - the Quadratus Llumborum and the posterior structures including the deep paraspinal muscles Multifidus and Rotatores and others. Further, there is the large back muscle Latisimus Dorsi that inserts into the thoraco-lumbar dorsal fascia and the Gluteal muscles that also do so and provide additional tension to the structures. Finally, there is the diaphragm above and the pelvic floor below that both play a significant role in providing true core stability.

Key core exercises tackle all these muscles. Front, back, sides, top and bottom. The secret is that it is not possible to compress water, and so by having a dynamic compression of the contents of the core, stability is created whereby the segmental instability described above is restricted from movement by the compression of the abdominal contents. Make sense?

There are other considerations such as muscle tightness and joint restriction above and blow the spine that contributes to the load at the unstable segment, perhaps perpetuating the instability and the consequence of that instability

on the pain one experiences. For example, the Hamstrings insert on the Ischeal Tuberosity and it is easy to imagine how the tight hamstrings would limit the ability of the pelvis to tilt forward during forward bending, which means that as one bends forward, the unstable segment in the spine would carry the load INSTEAD of the hamstrings. And because it is moving under load more than it should, and because the motion takes it past normal ranges due to sheering, an unstable segment is more likely to become even more unstable causing yet more pain and dysfunction as time passes.

What this means is that core stability needs to be a priority, but normalizing hip and thoracic spine mobility also need to be addressed for the core exercises to matter and for their effect to last.

Why does Aerobic Exercise Help My Neck Feel Better?

2008-12-03T21:42:00.000-08:00

The case for aerobic exercise in management of neck pain is an interesting one. At first blush, it does not seem to make much sense, but lets look a little closer.

Besides the obvious short term benefits of aerobic activity, including improved circulation and muscular relaxation as well as pain inhibition. Aerobic exercise causes one to breathe deeply by expanding the rib cage, which is obvious lower down in
the rib cage. That process is really designed to get oxygen deeper into the lungs during exercise when more oxygen is needed in the working muscles. One thing often overlooked is that the rib cage is also expanded in the region of the upper rib case with the upper ribs expanding upwards to further expand the lungs. This upper rib cage action is controlled by the accessory muscles of respiration which are mostly neck muscles.

The cervical spine, the rib cage and shoulder share many muscles, muscles that originate in the cervical spine, for example and insert into the first two ribs like the Scalene muscles, or muscles that originate on the Scapula and insert into the cervical spine like the Levator Scapula.

The Levator Scapula, because of this relationship is the muscle primarily responsible for the experience of a stiff neck.

Aerobic exercise raises the body temperature, relaxes the neck muscles, improves circulation, and calms the mind through the manufacture of endorphines, natural opiates, even as it really helps to reduce neck pain.

I routinely advise people suffering cervical spine dysfunction to perform aerobic exercise as a critical component of their rehab program. It helps tremendously.

What is a Forefoot Varus?

2008-12-02T10:32:00.000-08:00

This topic is the source of a great deal of misunderstanding. First, lets define some terms:
- "Supinated" and "pronated" are POSITIONS
- "Supination" and "Pronation" are MOTIONS

The whole body supinates and pronates during normal everyday activity. Gravity is trying to squish us into the ground (pronate us) and we resist that force (by supinating). Every step we take causes us to go through pronation and supination at every joint in the body.

The foot is said to be pronated or supinated. This is in reference to the subtalar joint, and specifically to a position called subtalar neutral (where the rear foot is neither pronated nor supinated).

When the forefoot is supinated relative to the rear foot, the condition is referred to as a forefoot varus.

So in other words, when a forefoot is supinated it can appear to be pronated because the body will get the forefoot onto the ground by pronating somewhere. The thing of it is that the pronation that gets the foot on the ground actually occurs higher up the chain as in at the rear foot, the ankle, the knee,the hip or the pelvis and lower back. When this occurs at the subtalar joint, for example,it is not uncommon to see the knees achieve a valgus position (knock kneed).

When a foot APPEARS pronated, one first has to determine if the foot ITSELF is pronated or if it just APPEARS to be pronated. It is easy to confuse the appearance of pronation in the case of a forefoot varus where the forefoot is effectively supinated. The nature of the condition causes failure in teh foot, at the ankle, at the knee and at the hip.

The incidence of this condition is 8% of 116 female subjects (McPoil et al, 1988) and 86% of 120 male and female subjects (Garbalosa et al, 1994).

There are three patterns of compensation:
- uncompensated
- fully compensated
- partially compensated

Forefoot Varus deformities produce numerous associated pathologies, including:

- shin splints
- plantar fasciitis
- tibialis posterior tendonitis
- patello-femoral syndrome
- lesser digital deformity
- hallux abducto valgus
- lower back pain
- sciatica
- metatarsal stress fracture (see Hughes, 1983)

Varus problems are easily treated through the application of Custom Orthotic Therapy.

Happy Thanksgiving!

2008-11-28T16:20:00.000-08:00

Just a brief note to wish Happy Thanksgiving to one and all.

Personally, I am thankful or my family, my good health and my good fortune being alive on planet Earth and resident in a free country, (the greatest democracy ever conceived).

I remind my kids every day that by having our family close, having a warm home to sleep in, and food on the table, makes us among the most fortunate people on earth.

Neil

Welcome to My BLOG

2008-11-27T13:23:00.001-08:00

Bilateral Distal ITB Pain After Long Downhill Runs

2008-11-26T15:23:00.000-08:00

Iliotibial Band Syndrome is actually a pretty common injury that occurs because of friction distally as the structure is stretched over the lateral femoral condyle the distal end of the long bone of the thigh. The reason this occurs is because there is a moment during the range of motion where the stretch is actually amplified by the greater trochanter of the hip which the ITB crosses over as well. When the structure is stretched over BOTH boney prominences the ITB is stretched maximally and is susceptible to failure, usually at the distal end, were it is not as wide. This actually occurs when the hip and knee are both slightly flexed, the position you are in all the time while running down hill, every step.

The ITB is made of collagen, the most prevalent protein in the animal kingdom. It is a true dense connective tissue.

Collagen is an organic crystal that actually fails gradually. Fibril by fibril. As the fibrils fail, the structure becomes weaker and eventually, enough fibrils fail that even the fibers are damaged causing pain structures to be stimulated and in turn, a local inflammation response occurs. When that occurs, you feel pain.

Treatment should be a combination of ice, NSAID's, gentle stretching, rest and eventually, strengthening. Orthotics are a consideration because there might be a biomechanical component to your injury. I like The Stick as a tool as well. The key is to be patient. Because this is essentially a dense connective tissue injury, this injury really needs to heal before you tackle the next hill.

The time frame looks like this:
- 3 weeks from the date of the injury to return to about 20% strong,
- 42 days to about 40 % strong and
- 90 days to about 90% strong.

My advice is to take 6 to 12 weeks off before running hills again immediately after you get hurt, and focus on the treatment you need to return to normal activity as quickly as possible. Although, that said, you should be able to run up hills before you will comfortably manage the flats or downhill runs again. The bike can be a bit risky for the distal ITB, because repetitive pedaling could irritate the tissue as it crosses over the distal femur. Be cautious about riding too many miles too early. This goes for running too. Be alert to the way you are feeling as you build your mileage, and dial it back if the outside of the knees starts to hurt. Build your mileage gradually once you are feeling good, and be especially cautious during the down hill sections.

The good news is that once it is better, you should be able to run without fear again.

Who Needs Orthotics

2008-11-26T10:55:00.000-08:00

Biomechanics is one of my favorite subjects. First of all, I believe that structure governs function. Lets face it, we are not perfectly constructed and so it stands to reason that a little help here and there might be really very helpful overall.

Orthotics, or as I prefer to say, Custom Orthotic Therapy, is appropriate when the biomechanics are such that the knee is thrown into too much valgus or varus.

Custom orthotic therapy modifies a shoe's internal structure so that the foot, ankle and leg are better aligned for efficient movement and force dispersion. Orthotics are custom made because each patient has different biomechanical problems in his or her feet. When orthotics are installed the biomechanics of the lower extremities are altered so that impact loading and movement become more efficient. Athletes can improve their quickness and balance and reduce risk of injury because orthotics improve the energy absorption characteristics of the lower quarter during impact loading activities.

There is a significant difference between off the shelf devices and custom built devices. Custom orthotics therapy is not simply “putting an arch support in the shoe.” Orthotic therapy is a biomechanical solution to a biomechanical problem. We find that in conjunction with good physical therapy rehabilitation strategies, especially hip muscle training, custom orthotics therapy is often the key intervention that helps a person recover fully.

Biomechanics: The Physics of Movement

We live in an environment that forces our bodies to react to gravitational forces. With every step we take, our skeleton's alignment and structure influence the process of absorbing and releasing the energy that motion and gravity create. The feet have two functions in life. The first is be a mobile adapter. And to do this job, our feet are highly adaptable. As they hit the ground and begin to absorb load, the motion they undergo is called pronation. The structure and alignment as well as the flexibility of our joints determine just how much energy the lower extremity chain (foot-ankle-knee-hip-pelvis-lower back) can absorb. Should the foot be restricted, the energy is absorbed higher up the chain. For different reasons, both flat and high-arched feet channel a large amount of energy to skeletal structures high in this chain—especially the knee and the hip—making those structures more susceptible to injury.

For example, it is common for the kneecap (patella) to develop pain because a flat foot forces the patello-femoral joint to absorb more energy. Running sports add "impact loading" to the equation. Running and jumping amplify the effects of failed biomechanics. Sprains and strains are likely to occur when joints are poorly aligned or when they absorb forces that should be directed to another part of the body.

A Real life example: As a down hill skier, our 30 year old male patient discovered that he had a very difficult time trying to make long carving turns. Instead his turns were short and sharp. Our patient presented with a high arch foot that had several other technical structural deficits. The biomechanical consequence of his foot mechanics was that he was unable to easily use his forefoot to control the inside edge of the ski. Instead, he had to roll his knee in to get his inside edge down. He presented in the clinic with knee pain. Manufacturing custom orthotics for his ski boots and exercise shoes that corrected the biomechanical deficit enabled him to use his forefoot to control his inside edge. The result: Long C-shaped curves and more controlled skiing, no more knee pain. Custom orthotics were the solution for his mechanical deficits.

Who benefits from Custom Orthotic Therapy?

While the medical literature does not support the idea that we all need orthotics, in our experience, anyone who is active on their feet can benefit from custom orthotic therapy. Those who stand, walk or run frequently—whether in sports,
at work or at home—will see improved performance and comfort with the aid of custom orthotic therapy. At the Sports Reaction Center, we make custom built orthotics for all types of athletic footwear, dress shoes and working shoes. If you suffer from foot, ankle, knee, hip or back pain, custom orthotics therapy could be the biomechanical solution for you. We make the devices as follows: First we evaluate the mechanical alignment of your foot. Next we cast the foot, placing the foot in a sub-talar neutral position. This position of the foot lets the pod-orthotist construct a cast of your foot in a known position. The cast is sent to a lab we use (Biomechanical Services, in Brea, California). Together with the pod-orthotist, we construct a cast with corrections that will adjust your biomechanics to optimize your function. And from that cast, the orthotics are manufactured. It takes about 3 weeks to get the finished products back, and then there is a break in period to consider as well.

My Neck Still Hurts Months After the Accident!!

2008-11-25T10:29:00.001-08:00

I have often seen post "whiplash" victims, rear end collision victims who sustained a true "whiplash" months and even years before who continue to suffer from post accident symptoms even though they have been treated by otherwise competent practitioners.

The secret to dealing with this sort of injury is to go back to the original accident and determine the mechanism of injury. Mostly, you will find that the anterior musculature of the cervical spine, especially the deep muscles including Longus Coli and the Scalenes as well as more superficial anterior muscles like the Sterno Cleido Mastoid are all really irritable.

The theory is that there was initial trauma with those anterior muscles being strained (occasionally the anterior Longitudinal Ligament and even the Anterior aspect of the discs are irritated as well. The theory continues that once irritated, because of the mechanics of the cervical spine, the size of the muscles and the consequences of contraction of the muscles due to the pain experienced after the trauma, that those structures essentially remain in a state of dysfunction for as long as they do until they are addressed directly.

At home, you can:
- Massage the muscles of the anterior cervical spine with your fingers. Be careful not to grab the front of your neck with your thumb because you can actually fracture the Hyoid bone that lives in that part of your neck!

- Back bend the neck as follows: Using a rolled up hand towel, put the towel behind the neck and hold on with both hands pulling downward with the hands. retract your face, (pull back) and then back bend over the towel until the head stops naturally, gently rotate your head left and right a small distance each way (pain free of course. Come back to upright and repeat several times (5 or 6 times to be precise).

- Posture, posture, posture.Try as hard as you can to catch yourself slouching. Try to sit and stand a little taller with your head positioned over your shoulder girdle. Catch yourself while on the phone, catch yourself while working at the computer, catch yourself while driving, catch yourself while standing inline.

- Stretch Gently. Only use the smallest forces to stretch the neck. The muscles are small. The joints as big as your little finger nail. Be gentle. Do NOT swing your head around in a biiiig circle. You can cause real damage to important structures if you do.

Try implement these ideas, and you will hopefully have more luck resolving your chronic neck pain than in the past.

The Mysterious Biceps Tendonitis

2008-11-24T08:22:00.000-08:00

I am often confronted by "hard to diagnose and persistent shoulder pain" that is incorrectly labeled "rotator cuff syndrome". The long head of the biceps is susceptible to the aforementioned "hard to diagnose, difficult to treat" tendinitis that once correctly identified can in fact be quite easily treated.

The key is to accurately locate the source of the pain as the biceps tendon long head in the bicipital groove, and then to make it geographically available so that treatment is accurately delivered. In the diagram below, you can see the tendon groove and the long head tendon that lives there.

In normal standing posture, the biceps groove lives toward the inside of the humerus closer to your body so that when your arm is against your body and your hand in front of you or at your side naturally, the biceps groove is "hidden". In this case, palpation of the groove is impossible, and direct treatment is ineffective.

In order to palpate the biceps groove, externally rotate your arm, and you will feel a little bump under your fingers as the edge of the groove goes by. If your shoulder hurts under your fingers as the groove goes by, you can safely assume that your biceps tendon is involved.

In order to effectively treat the long head of the biceps tendon, you need to expose the biceps groove by externally rotating the arm so that the biceps groove faces forward. Once positioned as described, you should perform ice massage for about 5 or 10 minutes over the biceps groove and humeral head, and in most cases that will make all the difference.

Acute Back Pain

2008-11-23T10:28:00.000-08:00

Here's the thing, even this episode is probably going to get better soon. Most acute episodes of Lower Back Pain (LBP) get better within 24 hours. If not, 8 out of 10 times, LBP resolves after a month, and 9 out of 10 times within two months. OK, but you hurt now, so what should you do?

During the last 26 years I have observed the following:

- Ice really works. Not blue ice packs, not frozen peas, not one of those cloth ice packs you get at a pharmacy, I am talking about refrigerator ice AND water in a plastic bag placed right onto the back in full contact with your skin. And it takes a half hour to an hour to penetrate to the deep tissues that need to be inhibited. 10 minutes per 1 cm, so think that the deep tissues are about 3 cm deep (if you are fat, add time accordingly!) What ice does is a. combat inflammation and edema, b. inhibit muscle guarding, and c. reduce pain.

- Get out and move. It is really important not to lie around when your back is hurting. You need to stay active. Ice will help, but go for a walk at a pace fast enough to work up a sweat. The reason for this is that inactivity promotes muscle guarding, and like the ice, activity helps keep the muscles from guarding. In the spine, the deep rotators "spy" on the adjacent vertebra up to five levels up and five levels down. Activity keeps your uninvolved muscles uninvolved, "quiet", if that makes sense.

- Rotation is key. In a half seated position (feet on the floor butt on the table, wrap your arms tightly around your chest, and rotate back and forth quite quickly (pain free though) for about 5 minutes every hour. Again, this both inhibits muscle guarding and encourages hydration and nourishment of the deep dense connective tissues. And it usually feels much better.

- 90/90 position for rest. Lie on the floor with your legs bent 90 degrees and the hip and 90 degrees at the knee, and your feet supported against the wall. This position is know to be the position with the least amount of intradiscal pressure compared to others.

- What if I am shifted? Well this is a complication for sure...but your first line of defense is described above.

- When should I see the doctor? If you have pain into your leg below the knee, numbness tingling or weakness, or intractable pain, any or all of these symptoms, go see your doctor.

- Is there an emergency situation? YES - if you lose control of your bladder, go to the ER - that is an emergency situation that is time dependent. Wait too long, and your bladder control will not likely return.

Finally, take a deep breath, use ice, go for walks, rotate, this too shall pass.

Joint Supplements: Good or Bad?

2008-11-22T09:28:00.000-08:00

One of the most common questions I am asked is "Do joints supplements work?"

The short answer is that indeed, they do. But like everything, there are complexities that are worth understanding.

First of all, understanding joint hydration is key. Our joint surfaces are lined by cartilage. The Hyaline cartilage that lines the surfaces of the bones derive some of their nourishment from the skeleton for sure, and the rest by imbibing joint fluid (synovial fluid) through a process of being compressed during movement (squeezing out contents) and then being decompressed (absorbing fluids) - sort of like a sponge. This process is normal and occurs with normal joint movements because as the joint moves from one end of the range of motion to the other, it goes through a natural compression and decompression phase with maximum compression occurring at the end of the range and maximum laxity in the mid range.

It is critical for joint cartilage to be hydrated because it is the water content of the cartilage that prevents compression of the cartilage. The chemical properties of water are such that water is not compressible, hence the field of hydrolics! In any event, in a perfect world, cartilage would maintain maximum hydration and joints would never fail. But even the natural flow of liquid into and out of the cartilage during normal movement requires that the cartilage has a mechanism to keep water in the cartilage matrix. Well, the cartilage cell, a chondrocyte, has the solution. Chondrocytes make two products effectively. Fiber to construct the architecture of the cartilage, and the chemical precursor molecules that are extruded into the extracellular matrix. Once extruded, these molecules spontaneously combine to form a long mucopollysacheride called glucoseaminoglycan (GAG).

GAG has an amazing property in that it has a high affinity for water, binding water to the point that it weighs 1000 times more wet than dry. So as long as the cartilage has GAG on board, binding water should occur without difficulty, right? Right. But, here's the thing. As we age, our cells make less GAG and the GAG that is made is of poorer quality and does not last as long. In any event, the half life of GAG is between 1 and 7 days, so continuous manufacture is needed.

This is where nutritional supplements come in. Theoretically, by taking joint supplements, you should be able to provide the cartilage the nutritional support to make more GAG, which leads to reduced joint discomfort and improved range of motion.

Because joint supplements are not a regulated product, the thing to do is to look at the science that supports using these products. For example, you would want to be sure that a. The product can be absorbed. Usually, there are at least two molecules of importance including glucosamnosulfate and chondroitinsulfate, and some studies suggest that the chondroitin is too large a molecule to absorb through the stomach, and injection is required for absorption. So the first consideration is bioavailabilty. b. Once absorbed, the next question is: Does it find its way into the articular spaces? c. The next consideration is this: Does it get absorbed by the cartilage? and finally, d. Does it demonstrate increased cartilage thickness and hydration.

It is important, from my point of view, to understand that if you are going to use a nutritional supplement, you should only do so if there is good science to support its use. Otherwise, you are simply making expensive urine! What is good science? A good research project should have a large study group (the "n"), it should be a double blind placebo controlled study, and the outcome should have statistical significance - which is to say that the outcome occurred because of the molecule (in this case) rather than by chance.

There are such products on the market, but you need to also know that there are other studies that show as much as a 95% variability between what is in the capsule and what is on the label! So another consideration is that you want a product that is manufactured to pharmaceutical standards with little or no variability from capsule to capsule and bottle to bottle due to production.

Additionally, I think it important to realize that cartilage is one form of dense connective tissue, but our tendons, capsules and ligaments are all essentially made of the same stuff as joint cartilage - collagen is the most prevalent protein in the animal kingdom. Its pretty much what we are made of - collagen plus a few specialized cells (like you eye cells, or nerve cells for example). So it stands to reason that our dense connective tissues in general also stand to benefit through the use of joint supplements. Anecdotally, I have seen many people of a certain age (like 45 and up) who have benefited greatly by taking a joint supplement for chronic tendinitis successfully. On the other hand, there is not good evidence that it works in the spine, although anecdotally again, I have had the experience of patients reporting otherwise.

OK, so what do I recommend? I believe that over the age of about 35 or so, active people should use a joint supplement for prevention and to enhance longevity, and the products I recommend are Cosamin DS and alternatively Move Free. Both of these products are of a pharmaceutical grade, and are well supported by excellent science that demonstrate bioavailablity, and increased cartilage hydration and thickness. The one drawback, however, is that they can increase your cholesterol. If you are subject to elevated cholesterol, but you are planing to try joint supplements to help you achieve a greater degree of joint comfort and improved function, you should monitor your cholesterol levels very closely.

The trouble with return to activity after ACL surgery

2008-11-21T07:37:00.000-08:00

The trouble with return to activity after ACL surgery

I often find myself talking people with recent ACL repairs to hold off on returning to running activity for as long as possible. The reason is that long term studies show that ACL repaired knees have more degenerative changes 10 years out than ACL rupture knees that were not repaired. I firmly believe that the reason for this is premature return to activity.

Returning to full function should be something that one does on a gradient. This means that functional strength needs to be fully restored over a six month period and the transition to athletic running (cutting, spinning, sprinting and generally changing direction) should be fully recovered after the ability to lunge, jump (take off on one leg land on two) and hop (take off and land on one leg) has been fully restored in all three planes.

Return to play, then should happen after that and again, there should be a gradual increase in field time at match pace. This is especially true in contact sports like soccer, basketball and football.

As an athlete in these sports, my advice is to work up to full match participation by gradually increasing the amount of time you practice at full speed and similarly gradually increase your time on the field in competition.

The moral of the story? Be PATIENT. Recover fully before participating, and protect your knee's long term health after ACL reconstruction.

Thoughts on Chronic Injuries

2008-11-20T11:15:00.000-08:00

In the musculoskeletal system, chronic injuries suggest that something is wrong somewhere else, or the injury would resolve, right? The way I look at the body is from the point of view that the systems need to work together for movement to occur without upset. The organization of the body requires mobility in some joints and tissues and stability in other joints and tissues.

I saw a fellow today who had chronic knee pain. Non specific anterior knee pain that came on for no apparent reason and has just been very persistent. Examination revealed a low grade chronic patella tendinitis (the tendon between the knee cap and the tibia). BUT, he also has tight IT Bands, tight quads, and a very stiff foot with a stiff ankle.

My point is that chronic injuries are usually chronic because OTHER issues need to be addressed. And the only way to figure our what else needs to be worked on or what must change is to be evaluated.

In his case, the evaluation revealed the tightness of the tissues described, and also a need to custom orthotic therapy to improve his overall structural biomechanical alignment.

My question to you is this: What would an evaluation of your biomechanics and function suggest for treatment to be successful?