November 28, 2008
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.
November 26, 2008
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.
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.
November 25, 2008
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.
November 24, 2008
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.
November 23, 2008
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.
November 22, 2008
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.
November 21, 2008
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.
November 20, 2008
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?