I don’t know why, I never run behind.

I set my wrist watch an hour ahead. That way, even if I am behind, I’m still way ahead in my own world.

Anyways, I asked a patient what their book was about and in return [...]]]>

What are you reading?

People leave books in our office all the time. Usually novels.

I don’t know why, I never run behind.

I set my wrist watch an hour ahead. That way, even if I am behind, I’m still way ahead in my own world.

Anyways, I asked a patient what their book was about and in return they asked me what I was reading.

Here’s the list:

Low Back Disorders by Stuart McGill.
A great work is one you can read over and over and get something new each time. I think this is round number four.

Reasearch Review Services weekly posts. A group of Canadian health care providers supply research reviews concerning musculoskeletal health care about twice per week. It’s a great service–even if it does make me feel lazy.

Netters Anatomy and Primal Pictures. There’s only a finite number of muscles, tendons, ligaments, nerves etc but there are a lot. I’m trying to make as detailed a map in my head as possible.

Musculoskeletal MRI. By Helms et al.
A good way to respect pathology (broken things that can’t be fixed) is to look at some everyday. That means quicker referrals and better outcomes.

Physiology of Joints by Kapjandi.

Oh, and of course, the Twilight Series.

P.S.  Stop inviting me to book clubs.  I was joking about the Twilight Series.

3. Respect Cumulative Loads

Translation: Don’t be afraid to take a day off.

Load versus capacity.

That’s the only equation that matters in respect to who gets injured, when they get injured, and just how bad the injury [...]]]>

Antioxidants

As promised, here’s part two of last weeks entry: Five Things to Make Running Easier (Part I)

3. Respect Cumulative Loads

Translation: Don’t be afraid to take a day off.

Load versus capacity.

That’s the only equation that matters in respect to who gets injured, when they get injured, and just how bad the injury is.

In an earlier post, I elaborated extensively on this topic (see Load vs. Capacity 101).

Following that idea, it’s easy to see how rest can be just as integral to performing well, and more importantly, staying injury free, as actually logging the miles.

What you do today, adds to what you did yesterday, last week, last month and even last year!

For many runners, bikers, swimmers etc. training becomes an obsession. Programs are designed. Programs are written. And, unfortunately, too often, programs are followed.

A training program is a template. It should be open to changes.

Many injuries are the result of too rigorous adherence to the plan.

Chances are, if you feel like you need a day off, or a smaller workout, you are probably right.

Don’t be afraid to trust that inner voice, it may be your body telling you you’re about to tip the scales.

4. Antioxidants

Research is beginning to hash out the importance of scar tissue and adhesion formation to musculoskeletal (and other system) dysfunction.

Much of the same research is showing a direct link between adhesion formation and free radicals.

Without getting into too much detail, the pathway goes something like this:

Oxygen levels in muscular tissues decrease as they are contracted repeatedly or during sustained contraction (running, riding etc). Metabolic processes in low oxygen states produce free radicals as a by-product. Free radicals stimulate the production of adhesion and scar tissue.

In short: Muscle contracts. Oxygen levels drop. Scar tissue is produced.

This is where antioxidants come in.

Antioxidants work as free radical scavengers in the body. Like bounty hunters, they search out and destroy these free radicals.

More antioxidants = Less free radicals = Less adhesion/scar tissue.

Sounds good to me.

This, among many other reasons, is also why a multitude of products have hit the market touting the benefits of antioxidants in recent years. Many of them are “super juices.”

Supplements are fine, regular good dietary habits are better.

If you make a conscious effort to eat a balanced diet, you’re probably getting your fair share of antioxidants.

If you’re a fruits and veggies fan, you’re probably right on.

A summary on antioxidants including a list of the top 20 foods can be found here: http://www.webmd.com/food-recipes/news/20040617/antioxidants-found-unexpected-foods

5. Don’t Forget the Warm-up

When I tell people not to spend too much time stretching, one of the follow up questions is usually: What do I do instead?

When it comes to performing well and avoiding injury, the warm-up is king.

Think of the warm-up as a mini event.

Don’t be afraid to ease into your run or exercise program.

A well designed warm-up raises the body temperature and increases blood flow to the muscles that are going to be used. In essence, it “primes” the system.

Most warm-up programs call for 10-20 minutes of light aerobic work, followed by some light dynamic stretching (term stretching used lightly here), followed by sports specific drills (skipping, hopping, A-skips etc).

Again, this is just an example, and one for a hard workout day no less.

It should be scaled back to fit the situation, ranging from the example above, to simply working up to normal pace on an easy day.

So next time you go out for a run, don’t just close the door and go full steam. Ease into it, and you’ll see how much smoother it goes.

http://www.flotrack.org/articles/view/1750-andrew-middleton

Thanks for the shout-out Andrew, and best of luck at the LA Honda Marathon!

This means, for instance, in someone with low back pain the muscles producing “core stability” don’t work in the same manner as a “normal” person.  The internal oblique muscle, for example, [...]]]> In recent years an abundance of research has surfaced with regard to musculoskeletal care demonstrating abnormal motor patters (movement compensations) relating to pain syndromes.

This means, for instance, in someone with low back pain the muscles producing “core stability” don’t work in the same manner as a “normal” person.  The internal oblique muscle, for example, may turn on too early, too late, too much or too little.

These studies are often a very close variation on one theme.

Step one: take some people without pain. Strap on some EMG pads (this is an electrical machine that can read muscular output). Have them do a movement and record the amount of each muscles contribution to that movement.

Step two.  take some different people, this time with pain (usually a specific complaint like anterior shoulder pain, low back pain, hip pain etc.) and then have them repeat the same tests. Record the results.

Step three: compare and contrast.

Differences are often found in the groups between the sequencing of muscles used, amount of effort used, or even which muscles are used.

Step four: interpret and apply to practice.

This is a stellar example of scientific method. It also happens to produce some of the most important information concerning musculoskeletal care.

My problem with it isn’t the study itself, but usually in how the research gets interpreted or applied.

Take the 2003 study in Spine by Hungerford and Hodges. Their study found significant differences in activation of core muscles in people with and without sacro-iliac pain during routine tasks.

Great research. Very promising and worth looking into more. Great application to clinical practice too.

Then I read a review of the study.

The reviewer came to the conclusion, based on this study and some others, that patients with SI pain and low back pain, in fact, should be treated with exercises re-teaching their core how to work properly.

Whoa there. Don’t you think we should ask some more questions first?

Like:

Do the patient’s have pain because their motor pattern is different, or is the motor pattern different because they have pain (does the compensation lead to the pain or vice versa)?

What if some of the subjects without pain had a sub-acute low back issue or had a developing issue that hadn’t become symptomatic yet? Couldn’t that change the normative data?

Did any of the subjects have other contributing pain syndromes (hip, leg, shoulder pain etc.) that could have affected results?

Etc. etc. etc.

Which brings me to my point.

There is so much variation between subjects (people), environments (jobs, social activities, recreational activities) and pain syndromes (superior SI pain vs. lower SI joint pain etc) that its hard draw real clinical conclusions from most research.

The manner in which your body deals with musculoskeletal pain, by way of compensation at least, could be very different than someone else based on the above factors.

One person with low back pain could hyperextend his spine while walking, another, because he’d had a previous hip injury could shorten his stride.

Different factors, different result.

This is why we see chronic problems will to frustrate both patients and providers alike.

Especially if you’re not asking the right questions—or all the questions.

Moral of the story: beware of providers carrying research—me included.

I’ve heard this before somewhere.

Repeatedly I think.

I just can’t remember where.

Roughly translated I think it means; “pay attention dummy, you might miss something”.

It’s easy to go through the motions and get “stuck.”

I like to think I don’t do this at work.

Sometimes, though, it’s just hard to stay [...]]]>

A little reminder!

Be present.

I’ve heard this before somewhere.

Repeatedly I think.

I just can’t remember where.

Roughly translated I think it means; “pay attention dummy, you might miss something”.

It’s easy to go through the motions and get “stuck.”

I like to think I don’t do this at work.

Sometimes, though, it’s just hard to stay plugged in—even after two coffees, two Rockstars, and a five hour energy. (Caffeine is good for you if you selectively read the research.)

We try our best not to have it happen, but sometimes a report doesn’t get faxed, an exercise prescribed, or ice pack dispensed.

Just like for you, there are a lot of ball’s juggling sometimes.

I suspect it’s the same way for most healthcare providers.

So, if it seems that this has occurred, don’t take it personally.

Just remind us.

And blame it on the front desk if you can.

That’s what I do.

Now, if I could just remember where I heard that before.

It’s a dirty word(s).

Not because of what it means. But because of what most people think it means.

Patients and providers both.

If I had a few bucks for every [...]]]>

Plantar fasciitis

I’m going to start a petition.
No one, or a least very few people, should be able to use the term plantar fasciitis.

It’s a dirty word(s).

Not because of what it means. But because of what most people think it means.

Patients and providers both.

If I had a few bucks for every time a patient told me their therapist (doctor/friend/neighbor) told them they had plantar fasciitis, and then pointed to a structure nowhere near their plantar fascia, well…I wouldn’t be writing this blog.

Here’s a quick checklist before we move on:

• If your heel or arch hurts, it doesn’t automatically mean you have plantar fasciitis.
• If you’ve had multiple treatment interventions but the pain remains, it might not be plantar fasciitis.
• If it hurts really bad, but not on the plantar fascia itself, it likely isn’t plantar fasciitis.
• If the pain you are experiencing isn’t even on the foot, I’m pretty sure you don’t have plantar fasciitis (true story).

Contrary to popular belief, plantar fasciitis and heel pain are not analogous.

Plantar fasciitis means inflammation of the plantar fascia—literally.

It also means that, if the plantar fascia isn’t inflamed or degenerated, as in plantar fasciosis (loose interpretation of the word degenerated here), then it isn’t plantar fasciitis.

Fact is. There are a whole bunch of conditions in the foot that can produce heel pain.

There are even some issues far removed from the foot that can masquerade as “plantar fasciitis.”

In some cases, without a doubt, it is the correct diagnosis.

In others, it’s not quite right, or at least not the whole story.

And in even others, it just plain lazy.

There aren’t that many structures on the bottom of the foot. A handful of muscles, tendons, ligaments and nerves make up the bulk of the soft tissues in the region and these are the likely culprits in heel and arch pain (fractures and radicular symptoms not withstanding).

The plantar fascia, a prominent fibrous band, stretching from the calcaneus (heel) forward into the foot and connecting with slips to each of the toes, is the most prominent and superficial of those structures.

As such, it is the easiest and most readily available culprit, so it gets picked on, often when it’s not the culprit.

It seems harmless.  Silly, even, to make a fuss about it.

Until you consider that diagnosis dictates treatment and treatment is only effective when it’s matched with the right problem. (The old hammer and screw analogy)

In short, proper treatment depends on proper diagnosis.

Heel and arch pain can arise from many local causes aside from the plantar fascia such as: medial calcaneal nerve entrapment, lateral plantar nerve entrapment, medial plantar nerve entrapment, flexor hallicus longus tendinosis, or fat pad syndrome just to name a few.

Proper diagnosis of the problem often relies on specific palpation (evaluation by feel) of the involved tissues.

The problem is, all of these structures, and many more are jammed together into a very finite amount of space.

Some of them are not much larger than a few grains of sand or a strand of fishing wire.

As such, being off just a millimeter or two, not being skilled or experienced enough to interpret what is felt, or even worse not knowing that the structure is even there, can be the difference between an accurate diagnosis and one that is doomed to fail.

As you can guess, what often occurs, is that many revert back to the “elephant in the room”—the plantar fascia.

Unfortunately, many evaluations for this condition don’t get a whole lot more detailed than this:

“Hey doc, my heel hurts really bad.”

“Oh really, where exactly?”

“Right here doc,” patient pointing to his arch.

“Well you must have plantar fasciitis,” doctor from across the room.

I wish it were that easy, or that I were that good.

1. Stop Stretching
It seems like all the time you’ll hear a coach or a sportscaster say how a great athlete does “all the little things to be successful.”

Here’s a little tip to make that list of little things smaller.

Stop stretching—it’s probably messing you up.

As an athlete you [...]]]>

Foam Rolling

1. Stop Stretching
It seems like all the time you’ll hear a coach or a sportscaster say how a great athlete does “all the little things to be successful.”

Here’s a little tip to make that list of little things smaller.

Stop stretching—it’s probably messing you up.

As an athlete you constantly overload (train) your muscles, tendons, ligaments and your body as a whole in an effort to get better.

You stimulate your body to “adapt” to the training demands you place on it.

Muscles for instance, get bigger (hypertrophy), develop more fibers (hyperplasia), and become more efficient.

One side affect of overloading soft-tissues, though, is the development of adhesions, or scar tissue.

So, in effect, the development of scar tissue is a side effect of training.

That’s exactly why stretching does not make much sense.

Picture a healthy muscle—soft, supple and pliable. Now, picture a bunch of thickened, hardened, scar tissue right in the middle of it.

Having trouble? Think of two rubber bands tied together in the center by a big rope.

Now take that rubber band-rope-rubber band muscle and pull from both ends (stretch).

What would happen?

That’s right, the rubber bands would stretch, but the rope wouldn’t move much, if at all.

The only thing you’re going to accomplish by stretching in this case is make the rubber band (healthy muscle) stretch too much to compensate for the rope (unhealthy tissue).

Now you’ve got two problems.

2. Roll Instead

Because the development of adhesions and scar tissue is the primary unwanted side affect to training or everyday stress, it makes a lot more sense to spend your time on foam rollers and trigger point balls.

These tools aren’t exactly ideal, and they’re definitely no substitute for a sure handed manual therapist, but they can be at least somewhat effective at limiting the unchecked development of adhesion and fibrosis in muscles, tendons, ligaments etc.

A quick thought on how these work.

Adhesions are focal areas of thickened hardened tissues that take up space inside normal tissues.

Foam rollers and trigger point balls apply pressure directly to the areas often using you own body weight.

This would compact the adhesions, making them take up less space in the soft-tissues.

The good: this would allow the muscles to work better as there would be less tissue area impacted.
The bad: it doesn’t actually get rid of the problem tissue to any large degree, so it may just be buying you some time.

The above paragraph was all theory—my theory.

But so is almost everything else in conservative musculoskeletal health care.

At least it makes sense from a “common sense” standpoint.

Look for part II in the coming days.

Thanks again for your hamstring advice when I came to see you after PF Chang’s race. I have stopped stretching them. The last 2 weeks I have run 60 miles per week with [...]]]>

Stretching?

I got an e-mail from a patient yesterday. One case study does not constitute a statistically significant sample, but check it out.

Thanks again for your hamstring advice when I came to see you after PF Chang’s race. I have stopped stretching them. The last 2 weeks I have run 60 miles per week with no problems. I did a 22 mile run yesterday and felt great. When you told me not to stretch my hamstrings I of course thought you were crazy but I know your advice always works!! The countdown is on to the LA Mararthon less than 40 days away.
Thanks,
Kerry Camberg

Congrats Brett!

http://runningtimes.com/Article.aspx?ArticleID=18598

P.S. Take note of a little shout out about [...]]]> This is an article from Running Times featuring Brett Gotcher. Brett recently competed in the marathon in Houston, running a 2:10:36. This is the 4th fastest debut in American history. He is currently ranked 5th among active American runners.

Congrats Brett!

http://runningtimes.com/Article.aspx?ArticleID=18598

P.S. Take note of a little shout out about half way down the page!

Brett Gotcher 2:10:36