The Fifth Third Riverbank Run is coming up on May 12, 2012 and many runners have struggled through overuse injuries due to the vigorous training schedule. Illiotibial band syndrome (ITBS) is one of the most common and most debilitating overuse injuries that a runner may face. It is characterized by pain along the outside aspect of the knee joint and this pain can be accompanied with clicking. Usually the pain is worse with activities that bend the knee.

The iliotibial band (IT band) is a long fibrous band of tissue that runs along the outside of the leg. It begins up near the hip with a small muscle called the tensor fascia latae. Three other muscles attach to it including the gluteus medius, gluteus minimus and the vastus lateralis. From the hip it extends down to the outside of the knee where it inserts into the kneecap and lower leg. Often this is the site of painful irritation.

The main function of the IT band is to stabilize the outside of the knee and to assist the hip in abduction, a motion in which the hip moves outward. When weakness is present, this can lead to poor biomechanics during the contact phase of running. Runners are notoriously weak in the muscles of the core and the hip because their main means of training requires only forward movement. Because side-to-side movements are not required, the muscles that perform these motions become weak.

A growing body of evidence that suggests proximal weakness around the hip can contribute to poor mechanics at the lower extremity with activities like running. A study published in the Journal of Orthopaedics and Sports Physical Therapy demonstrated that competitive female runners with a history of ITBS present with different lower extremity mechanics. They found differences at the foot, knee and hip of the involved limb. It was established that when weakness is present, the lower extremity tends to roll inward which places stress on the IT band (as demonstrated in the picture below). These biomechanics can predispose an individual to syndromes like ITBS and other generalized knee disorders. Thus, if we can strengthen the muscles which dynamically control this inward force, we can reduce the stress on the IT band and over time eliminate pain.

Exercises like side leg lifts, clamshells, side stepping against resistance bands, and single leg balance activities work to increase the strength of the weak muscles. Also, working on dynamic control of the knee joint is important. Performing a single leg squat in front of a mirror while focusing on not letting the knee roll inward or dropping the pelvis will work at improving lower extremity biomechanics. This technique can also be utilized during a step-down or lunge.

Often, tightness within the IT band has been blamed for the cause of pain, but usually the tightness is a secondary response to the underlying weakness. This tightness may progressively worsen with overtraining. Other training errors like running on one side of the road (which often has a slight slope) may contribute to poor biomechanics. Daily stretching and ice are important initial treatments, but as stated above, many times ITBS is more complicated and will require extensive examination and treatment of muscular imbalance. Many patients recover from ITBS within a few weeks to a couple months if proper exercises are prescribed and appropriate rest has been granted.

So, while a majority of runners are pushing through the pain for the Riverbank Run, it may be a good idea to take the appropriate rest afterward and then treat it right. Get to the source not just the symptom!

 Ferver R, Noehren B, Hamill J, Davis I. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Orthop Sports Phys Ther. 2010:40(2):52-58.

By Adam McIntyre

Spring is here and the streets are beginning to fill with those individuals who get out and get active in this early warm weather. While exercise is one of the best things you can do for your health, remember that being on the road, while normally quite safe, can be a dangerous place in our culture of distracted drivers. Here are a few tips for safety while running and cycling.

Be conspicuous: A reflective vest, light colored clothing and blinking lights, especially near or after sunset, give drivers the best possible chance to see you and allow for ample passing room.

Plan your route: Little things like avoiding riding a bicycle on the road traveling west into a setting sun will keep motorists from being blinded by the sun and not seeing you. When running on a sidewalk, choose to run with the direction of traffic, so that vehicles turning right will be more likely to see you and not pull through the crossing area.

Know your rights: Bicycles, according to the Michigan Vehicle Code are entitled and subject to the same rights and rules as motorized vehicles being operated on roadways in Michigan. A bicycle may be operated on a sidewalk, but is not advised by the League of Michigan Bicyclists (Michigan's bicycle advocacy group) due to the hazards to the cyclist and pedestrians using the sidewalks.

Wear a helmet: The IIHS estimates that helmet use can reduce the risk of head injury by 85%. Visit your local bike shop to be properly fitted for a helmet. Remember, that all approved safety helmets (regardless of the price) meet the same requirements and will protect your head the same.

For more information on the rights and rules of the road while cycling, and answers to frequently asked questions about cycling visit http://LMB.org.

What does everyone want to drive? A luxury car of course. What does a luxury car have in common with our body and this blog. I educate all my patients regarding their musculoskeletal injuries and explain that our bodies are all like a car. If our body is a car then of course we all want to be a luxury car. What makes a car a luxury car? Luxury cars have big engines with significant horsepower and that car can pick up speed quickly and go fast down the road. A luxury car also has a smooth ride, which is provided by the suspension system. There is nothing better than a fast, smooth ride down the highway.

The musculoskeletal system is made up of predominantly muscles, connective tissue and bones and it gives structure to our body. The skeleton of our body is like the frame of the car. Without a solid frame the car or body is inefficient and does not tolerate physical impact well. In real life that means that good bone density provides a strong frame for our body and sets the foundation for all the other components of the body. The muscles and connective tissue of the body are like the shock absorbers and suspension system of the luxury car. Strong muscles provide power and speed for the body and muscle flexibility provides shock absorption. If the body is all muscle and with minimal flexibility in those muscles it is like riding in a large 1 ton pickup. That pickup will get you up any mountain but it sure will be a rough, bouncy trip. Each joint in our body contains articular cartilage which provides some cushion to the joint surfaces and facilitates smooth gliding within the joint. Articular cartilage is like the tires on our car. With aging and increase miles on our body or car the tires show wear patterns just like joints. Think of a total knee replacement as getting a new tire.

Osteoarthritis is wear and tear on our joint surfaces. If we drive the car (body) long enough we all get some degree of wear pattern on our tires (joint surfaces). What can we do to minimize our wear and tear within our joints? We need to keep our lower extremity muscles strong (pump up the shock absorbers) and flexible (suspension system flexible) to absorb the daily forces of gravity and body weight. If our muscles do their job then the joints (tires) do not take as much stress and will last longer before replacement is needed. Is it really that simple? Yes. Research has proven that patients with significant osteoarthritis within the knee joint responded well to a lower extremity strengthening and stretching program. Their pain levels decreased and their function improved. The osteoarthritis is still evident by X-ray but the pain had decreased because the joint surfaces were being unloaded by the muscles (suspension system).

As noted in a previous blog about osteoarthritis and body weight minimizing the stress on the joints (tires) is the key. Body weight reduction is one component of the solution to pain relief but it takes time and a whole lot of effort to reduce body weight. We also need to work on our strength and flexibility of our lower extremity muscles to provide that luxury car ride. Dream of being a Cadillac and cruising down that highway with a powerful, smooth ride. See the chart below to see how our other body systems work like a luxury car. Take care of that car and it drive forever.

By Adam McIntyre

As a cyclist and triathlete, I am always looking for a little bit of free speed. I have spent more money than I care to have my wife know about on time trial helmets, lycra skin suits, wetsuits, heart rate monitors, tri-specific bike frames, and spent time practicing throwing my bike into a rack, removing my helmet and slipping my still wet feet sockless into shoes to shave a few precious seconds off my lumbering triathlon pace.

What is it about endurance athletes and gear? Are we slaves to the marketing companies in a never ending cycle of trial and error? As I eyeball my competition in the pre-dawn hours before a triathlon, I have noticed a growing trend, a combination of too-short shorts and knee high socks, a combination I haven't seen since the days of Bill Lambeer and the "Bad Boys." Upon further investigation, I have discovered that these are compression socks, and they apparently serve a purpose.

Performance apparel marketing has been quite successful in getting their products out to the public. In 2008, compression socks were seen on 415 of the 1,677 athletes at the Kona IronMan World Championships according to the New York Times1. Compression clothing companies have many claims printed on their boxes, from improved muscle performance and oxygen delivery to reduced cramping and improved blood flow. While compression socks have been used for years for patients with compromised blood flow, the performance claims have drawn my attention. These compression garments come in a variety of sizes and styles, from calf sleeves to full socks and even body suits. In a never ending quest for those extra few seconds in a triathlon, I am interested to see if these items would have a place in my ever growing "gear junkie" bin.

My fiscally responsible side tells me, however, that I should look a bit further into the claims that apparel companies make before I plunk down my hard earned money on some splendidly stylish knee socks. A review of the medical and sports journal archives will definitely show that the popularity of compression garments has drawn the attention of researchers as well.

According to a study published in 2008 by the International Journal of Sports Physiology and Performance, lower body compression garments were not effective for improving performance during a cycling time trial simulation2 (one hour time trial). Additionally, the same journal in 2011 studied the effects of compression garments in runners; they, too, found that there were no appreciable gains when wearing compression garments3. These results are further corroborated by a study which compared differing types of compression garments to no compression garment in sub-maximal and maximal running performances. This group studied many variables relevant to the endurance athlete and found no statistically significant gains between different types of compression garments and those with no compression4.

But what other gains may be out there? Compression garments have also claimed to improve recovery and, not surprisingly given their popularity, this claim has not gone unnoticed by researchers either.

In 2010, the European Journal of Applied Physiology reported improved recovery of exercise-induced muscle damage (something that is all too common among athletes) following high load exercises through the lower extremities in female athletes5 (garments worn for 12 hours following the workout).

So, compression apparel will help me recover faster, right? Well, not so fast. When compared to hot/cold immersion (contrast-bathing) and active recovery, compression garments seem to show similar positive effects, not necessarily better6,7. These reports demonstrate what at this time seems to be the most valuable use of compression garments, recovery from an event or training session. Facilitating recovery with active interventions is something that athletes at the highest levels can be seen doing following their competitions. Cyclists can be seen spinning their legs out after a race, runners receiving a massage, or simply sitting in an ice bath.

But what about the time crunched weekend racer? I know that there are weekends where I will have to travel two hours to a competition, and will sit in the car for two hours after my event with plenty on the honey-do list when I return home, so active recovery is not exactly in the cards all of the time. My final opinion is that if you are training on a daily basis throughout your race season, compression garments may help those Monday training sessions hurt a little bit less and allow you to train at a bit higher level, but aside from any psychological boost on race day, unless you are getting paid to support a company, leave compression socks for your post race podium ceremonies or save the cash for entry fees.

Guest Blogger Adam McIntyre: Adam is an outpatient physical therapist at the Grandville Visser YMCA Spectrum Health clinic and is an avid cyclocross rider with the Bissell/ABG Cycling Club and competes in many triathlons in the Midwest region.

1) Shea, Sarah. New York Times; 10/23/2008, p10, op.

2) Schanlan A, Dascombe B, Reaburn P, & Osborne M. The Effects of Wearing Lower-Body Compression Garments During Endurance Cycling. International Journal of Sports Physiology and Performance, 2008, 3, 424-438. Human Kinetics, Inc.

3) Dascombe B, Hoare T, Sear T, Reaburn P, & Schanian A. The Effects of Wearing Undersized Lower-Body Compression Garments on Endurance Running Performance. International Journal of Sports Physiology and Performance, 2011, 6, 160-173. Human Kinetics, Inc.

4) Sperlich B, Haegele M, Achtzehn S, Linville J, Holmberg H, & Mester J. Different types of compression clothing do not increase sub-maximal and maximal endurance performance in well-trained athletes. Journal of Sports Sciences, April 2010; 28(6): 609-614.

5) Jakeman J, Byrne C, & Eston R. Lower limb compression garment improves recovery from exercise-induced muscle damage in young, active females. European Journal of Spplied Physiology, 2010; 109:1137-1144.

6) French D, Thompson K, Garland S, Barnes C, Portas M, Hood P, & Wilkes G. American College of Sports Medicine, Medicine & Science in Sports & Exercise. 2008 Jul;40(7):1297-306.

7) Gill N, Beaven C, & Cook C. Effectiveness of post-match recovery strategies in rugby players. British Journal of Sports Medicine, 2006; 40:260-263.

Snowboarding started to become more popular in the 1990s and has continued to attract people of all ages. Many ski areas have developed terrain parks that have half pipes, rails and kickers which create an element of excitement but also presents some safety considerations. Despite the overall low injury rate (fewer than 1 percent), there are several considerations that may help to prevent these injuries.

Beginner teenage snowboarders (those younger than 16) have the highest risk of injury, and the highest risk falls is on the first day of participation. I imagine that many teens received snowboarding gear over the Christmas season, and they will hit the slopes with no formal lessons and no background in winter sports. These teens have the highest risk of injury and the studies prove it.

Over the years there has been a large increase in the use of helmets on the slopes. This is due to the increased awareness of head injury and it has helped significantly to reduce the rate of head injury. Injury prevention is the key in all sports and it is imperative to protect against head injury. Did you know that head injury is not the most common injury in snowboarding?

Upper extremity injuries dominate the sport, and the most common injury occurs at the wrist. Maintaining a stable stance while snowboarding is difficult because both feet are fixed onto the snowboard. When balance is lost, an individual cannot step out to prevent a loss of balance; therefore, the instinctive reaction during a fall is to break the fall with an outstretched hand.

Despite the fact that the wrist is the most frequently injured joint, the use of wrist guards remains low. It has been reported that fewer than 10 percent of all boarders wear guards. It is very important, especially in the high-risk population, to wear protective gear. Some studies have shown that snowboarders who wear wrist guards are half as likely to injure their wrists as those who do not wear wrist guards. Overall, research has proven time and time again that wrist guards reduce the risk of injury (Russell).

Wrist fractures are the most common of the wrist injuries and these injuries can be very complicated and can lead to a lifetime of dysfunction. Prevention is the key, and the solution seems so simple! If you would like to know more about winter sport safety, a wonderful website you can visit is www.ski-injury.com. This website provides updated information with an evidence-based background.

Russell K, Hagel, Francescutti LH. The effect of wrist guards on wrist and arm injuries among snowboarders: a systematic review. Clin J Sport Med. 2007;17(2):145-50.

Do your joints ache when the weather changes? I treat a wide variety of patients in an outpatient setting and many patients over the years feel that their pain is related to the weather. It is commonplace for a patient to have increased pain on cold or rainy days, and I have often wondered if there is any scientific evidence to support it. Personally, I have had two knee surgeries and I undoubtedly also experience increased discomfort and aching prior to a rainstorm. The question is – is there any science to prove it or are we all just crazy?

Changes in barometric pressure are often to blame for changes in joint pain. Barometric pressure is often called atmospheric pressure and it is defined as the force that is exerted on objects by the weight of the atmosphere above them. Severe weather may indicate that areas of low pressure may be moving in. Joints contain sensory nerves that respond to changes in pressure. These receptors may contribute to the altered sensation during weather changes or when people experience pressure changes as they travel from low to high altitudes.

Some studies support the claim that weather affects joint pain. A study released in 2002 concluded that "low back pain might be aggravated by atmosphere depression in patients with lumbar disease associated with the vacuum phenomenon" (Kasai). Other patient populations that seem to be more afflicted by the weather are those with chronic joint pain, rheumatoid arthritis, nerve entrapment, osteoarthritis, lower back pain and those who have had a limb amputated.

In 2011, a group of researchers looked at the associations between weather, psychology and rheumatic pain. They reported that 84 percent of subjects believe there is an association between the weather and pain, and 57 percent claimed that they have the ability to forecast the weather (Cay). After assessing several variables within their study, they concluded that the only significant association was between arthritis symptoms and the Beck depression score. No true statistical significance between pain and the weather could be determined.

Overall, I was unable to find a substantial body of evidence that supports the theory that weather influences pain. On the other hand, I was also unable to find evidence that disputes the relationship. So as long as science fails to prove or disprove the theory, the age-old belief will continue and I will continue to predict the weather with my knee pain.

Cay HF, Sezer I, Firat MZ, Kacar C. Which is the dominant factor for perception of rheumatic pain: Meteorology or psychology? Rheumatol Int. 2011 Mar;31(3):377-85.

Kasai Y, Takegami K, Uchida A. Change in barometric pressure influenced low back pain in patients with vacuum phenomenon within lumbar intervertebral disc. J Spinal Disord Tech.

Trigger points are small, taut bands in muscle that are hyperirritable and painful to compression, contraction, stretching and extreme temperatures. Trigger points can also be found within the muscle-tendon junction, bursa and in fat pads. Often patients will complain of having painful knots in their muscles. For example, the upper trapezius muscle, which is on both sides of the neck, is a frequent area of complaint. The calf is another commonly affected area. These trigger points can cause local pain or they can refer pain to other parts of the body.

Trigger points may be caused by direct trauma, muscle strain, arthritis, myositis (inflammation of the muscle), an underlying joint dysfunction or faulty movement patterns, among others.

Studies have demonstrated that trigger points are clinically relevant for patients with mechanical neck pain, lateral elbow pain, unilateral migraine, shoulder pain, heel pain and chronic tension type headache. Some theories suggest that trigger points can alter the motion around a joint which can change normal feedback to the brain and over time lead to impaired movement and muscle imbalance. This can lead to early fatigue and decreased efficiency with motor skills.

Treatment of this dysfunction can involve what we typically call trigger point release. In this, a physical therapist applies pressure to the trigger point until it softens. This pressure has been found to be beneficial in treatment of heel pain when manual therapy is applied to the calf (Renan-Ordine). Foam rollers and tennis balls can be used to apply pressure at home, and many commercial tools are designed to get hard to reach areas along the spine. Self-treatment has been found to be effective in treating trigger points (Hanten), but issues related to pain are often more complex than just treating the trigger point.

A physical therapist can help find and treat trigger points. However, in my opinion, many times trigger points are not the primary cause for pain but rather a symptom of another underlying dysfunction. These problems can consist of a joint that is not moving correctly, overuse of a muscle due to poor mechanics or muscle imbalance, previous unresolved injury, or bad posture.

Over the years, I have seen several patients for neck pain. Many of these individuals undoubtedly have painful trigger points, but usually they are not the true cause of the pain. I have found that if the underlying dysfunction is identified and treated, the trigger points will calm down as well. In a sense, trigger points can act as messengers to communicate to us that we need to increase our awareness of dysfunctional behaviors, actions, habits and movements. If we treat the cause, we can also treat the symptomatic trigger point.

Sources:

Hanten WP, Olson SL, Butts NL Nowicki AL. Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Phys Ther. Oct 2000;80(10):997-1003.

Renan-Ordine R, Alburquerque-Sendin F, de Souza DP, Cleland JA, Fernandez-de-Las-Penas C. Effectiveness of myofascial trigger point manual therapy combined with self-stretching protocol for the management of plantar heel pain: A randomized controlled trial. J Orthop Sports Phys Ther. Feb 2011;41(2):43-50

The holiday season is upon us and it seems that every holiday party includes seasonal beverages and foods of many types, all of which are loaded with extra calories. For many people, this translates into seasonal weight gain—and a New Year’s Resolution to get back into shape. It is always much easier to gain weight than lose weight. Most of us lose this battle over time and a few years later we have gained 10 pounds without even realizing it. We all know that extra body weight has many detrimental effects on our body and the knee joint is no exception.

Osteoarthritis (OA) is defined as ‘wear and tear’ type of arthritis within the weight bearing joints, most commonly the knee and hip joints.

The exact etiology of OA is unknown but many risk factors that been associated with developing OA within the hips and knees. These risk factors include age (usually 50 years or older), gender (female more than male), occupational and sports related stress, and obesity. In most cases, the most controllable risk factor is body weight. We cannot control our age, gender and many times our physical work stresses, but we can control our body weight in most cases. A study published in the Journal of Arthritis and Rheumatism in 2005 illustrated that for each pound of weight reduction there was a reduction of four pounds of force exerted on the knee joint for each step taken during daily activities. This study included 142 sedentary, overweight and obese older adults with self-reported disability and radiographic evidence of knee OA. Biomechanical testing was performed to determine the knee joint forces and the intervention and control groups were followed over 18 months. The study also demonstrated that a body weight reduction of 5 percent over 18 months was associated with an 18 percent improvement in function as reported by the intervention group.

I have a special interest in this topic because I am living this scenario. I fit the risk factors—age 50, female, physical stresses on knee of kneeling, squatting and walking as a physical therapist all day long, and of course the dreaded excessive body weight. A recent X-ray illustrated I have moderate degenerative changes within both of my knees and due to a recent injury I am struggling with persistent left knee pain. Oh my! It sure is easier being the physical therapist giving out advice on how to relieve knee pain than being the patient trying to deal with the discomfort and exercising to lose that unwanted body weight. In a nutshell, research has proven that for each pound of weight I lose I will experience four pounds less impact force on my knees and my pain with dissipate and my function will improve. You do the math: Four pounds less force on the knee per every step taken during the day (usually 4,000 to 10,000 steps) adds up to some big unloading of the knee joint. I guess that means one fewer holiday cookie for me this season.

In the next blogs I will discuss different ways to exercise to burn calories and gain strength while trying to reduce forces on the hip and knee joints. Most people will say, “If my knee hurts when I walk, how do you expect me to exercise to lose weight and gain muscle?” We will address that issue and others. And guess what: I am living the dream myself so I can empathize with your struggles. Take a look at the blog I wrote on Nordic walking. That is a good place to start with exercising while unloading the knee joints.

Reference

Messier, SP, Gutekunst, DJ et al, Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis; Arthritis and Rheumatism, Vol 52, Issue 7, 2026-2032, July 2005.

Recently I wrote a blog on joint hypermobility and misconceptions about the phrase “double jointed.”  In that blog, I said joint laxity can be inherited or it can result from trauma.  Joint trauma can occur gradually over time due to an accumulation of small repetitive injuries or it can be due to one large traumatic event like a shoulder dislocation.  Nevertheless, this acquired joint laxity can be very detrimental.  Physical therapy in some instances can assist in stabilizing a joint, but in cases where there is joint damage, the hypermobility that was created must be surgically fixed.

The shoulder joint is a ball and socket joint.   The socket (glenoid fossa) of the joint is very shallow.  Because of this, the shoulder has the greatest natural mobility of any joint in the body.  This makes this joint vulnerable to injury and therefore it is also the most commonly dislocated joint. To compensate for the shallow socket a ring of cartilage, called a labrum, forms a rim around the edge of the socket.  This cartilage increases joint stability by making the socket deeper.

Shoulder pain that results from falling on an outstretched arm, repetitive overhead motions or lifting heavy objects can result in a tear of the labrum.  I have found that often these patients will have had persistent pain which is not relieved by rest and they do not fully respond to conservative therapies which may include stretching and strengthening.  They complain of a deep pain which is difficult to pinpoint and some patients may have a catching sensation. 

The labrum has poor vascularity especially at the top of the socket, and when the labrum is injured here it is called a SLAP tear (superior labrum from anterior to posterior).  A tear here can also involve the tendon of the biceps because it inserts into the superior labrum. This damage will not heal due to the poor vascularity and surgery is usually warranted.  This lesion is commonly found in overhead athletes.

A Bankart lesion is a labrum tear that commonly occurs in the lower half of the labrum.  These tears can be more commonly injured with a full or partial dislocation.  Often, after a traumatic shoulder dislocation, surgical repair is necessary. 

With careful questioning and assessment, a physical therapist can help determine the extent of joint damage, but referral for further consultation and testing is usually necessary if a labrum tear is suspected. 

In my career, it has not been uncommon to have patients walk though my doors and claim that they are "double jointed." Often, they will pull their shoulder "out of socket," bend their fingers or thumb back so far they can almost touch their wrist or hyperextend their elbows and knees. These are among the most common examples of generalized joint laxity that I see in the clinic.

So are joints really "double jointed"? Not really, but some joints have increased laxity, which allows them to move beyond what most consider normal. This increased laxity is termed joint hypermobility. Between 4 percent and 13 percent of the general population are born with joint hypermobility (Johnson). While not all these flexible individuals go on to have careers as contortionists, many use their mobility to their advantage. For example, many athletes including gymnasts, weight lifters, swimmers and dancers require increased joint laxity for superior performance. In addition to athletics, musicians commonly need increased mobility in their hands and fingers to play instruments like the piano or guitar. Training in certain sports can also increase joint laxity as repeated minor injuries can cause stretch to the capsule and ligamentous restraints. Consequently, hypermobility can either be genetic or acquired.

While hypermobility can be beneficial, many hypermobile individuals deal with pain and dysfunction related to the increased joint mobility. Because their joints are more lax, these individuals have a significant need for strength and stability. This stability can come through joint specific strengthening. A physical therapist can prescribe exercises to help minimize joint movement and stabilize the joint during activity. Often, joints that have increased laxity will only become painful or symptomatic during activities that repetitively place that joint in the extremes of its motion or during high performance athletics.

An example of this is the teenage volleyball player with natural joint laxity who experiences pain and "looseness" upon serving or spiking a volleyball. This athlete needs to work on strength of the shoulder girdle including the rotator cuff and scapular muscles. The goal of strengthening is to stabilize the joint. Often, an athlete will be able to control his/her symptoms with physical therapy as long as there is no injury to the joint structure. So while those who have a natural degree of hypermobility do not always have pain or dysfunction, it is necessary to recognize that with overuse and poor stabilization it may exist. A physical therapist is trained to identify if joint hyperlaxity is contributing to the pain. Traumatic injuries, like the football player who has suffered from multiple shoulder dislocations, may require more than physical therapy. Surgical intervention may be required if the joint integrity is compromised.

Source:

Johnson SM, Robinson CM. Current Concepts Review: Shoulder instability in patients with joint hyperlaxity. J Bone Joint Surg Am. 2010;92:1545-57

Facebook: Do you think you are double jointed? Read the latest You, Me & PT blog by Erin Burgess to learn what that really means.

Twitter: Do you think you are double jointed? Read the latest You, Me & PT blog by Erin Burgess to learn what that really means.

Probably the No. 1 question we are asked as physical therapists is, "How do you know if you should put ice or heat on an injured or painful joint or muscle?" The answer to that question is gets complicated, but in a nutshell we answer: "When in doubt, ice." The decision to treat with ice or heat is based on a few factors such how long since the injury occurred, the area of the body involved and the severity of the injury.

When an injury occurs, a chemical reaction within the tissues of our body occurs and inflammation is the result. If an injury occurs as a result of a trauma such as twisting your ankle while running, the reaction of the body will include mild tearing of the tissues surrounding the joint and disruption of tiny capillaries within that tissue. All of this causes an inflammatory response. This is considered an acute injury and ice is the appropriate treatment. Based on the severity of the twisted ankle, determine the duration of icing in days. If it is a simple twist with minimal swelling, ice may be needed for only three to five days or until the inflammation is significantly reduced or goes away entirely. If the twist was quite severe, the tissue will respond with significant swelling and also bruising along the sides of the ankle. This bruising indicates that quite a bit of soft tissue micro-tearing occurred. This type of injury may require a few weeks of icing or until the inflammation is decreasing and the person is regaining full range of motion within the ankle and foot. Do not believe the old saying, "Ice for the first 48 hours, then heat." The best approach is to ice the injury initially and keep the joint moving within a tolerable range of motion to avoid accumulation of swelling.

What if the swelling is minimal and it originates from severe osteoarthritis of the knee joint? When the source of the inflammation is a chronic irritation such as joint osteoarthritis (OA), ice may not be the answer. Many people with joint OA will use ice to help control pain within the knee, but ice does little to eliminate swelling within the knee. The knee will remain swollen to a certain degree until the OA within the joint is eliminated when the patient has a total knee replacement. The general answer for a chronic joint irritation is, "Use ice for pain control or use heat to loosen the stiff joint." It is a personal preference for the patient and he or she can change the approach to ice or heat whenever he or she feels change is necessary.

So what is the take home message? When in doubt use ice and use heat only when a joint or muscle seems stiff and there is minimal swelling. When using ice, it is also important to use the acronym RICE.

R est: Induce relative rest to promote healing

I ce: Apply ice pack

C ompression: Apply light compression wrap (such as AceTM Wrap) to help minimize swelling

E levation: Raise the injured body part above heart level; gravity will drain the swelling back into the lymph system of the body (trunk region)

We recommend patients use large bags of frozen vegetables such peas or corn as reusable ice packs or the following ice pack recipe.

Ingredients

1 part rubbing alcohol / 2 parts water

Procedure

1. Purchase a standard size rubbing alcohol bottle found at any pharmacy
2. Pour rubbing alcohol into a 1 gallon Ziploc bag
3. Add 2 bottles of water to the Ziploc bag
4. Remove excess air in the bag and seal
5. Squeeze the sealed bag to mix contents
6. Place bag flat in freezer overnight; you may want to place the first bag into a second Ziploc to prevent leaking
7. Place a thin towel over the injury
8. Place the bag of frozen slush on the towel over the injured area

Apply ice for 20 to 30 minutes, one to three times per day based on the severity of the injury.

Hamstring strains account for a large percentage of injury during sporting activities at high school, collegiate and professional levels. Of alarming importance, one third of all hamstring injuries will recur with the greatest potential of risk being within the first 2 week following return to sport (Sherry). Due to the high occurrence and reoccurrence rate, hamstring strains should be properly rehabilitated prior to return to sport.

The hamstring is a group of three muscles that extend up the back of the thigh. These muscles attach to the bottom of the pelvis on what we call our "sit bones" and extend past the knee joint to attach to the lower leg.

A "pulled hamstring" occurs commonly during sports that involve sprinting and running. Most often this injury occurs when the leg is at the end of its swing phase as it prepares the foot for contact. At this point, the hamstring is lengthening as well as absorbing force and therefore it is susceptible to injury. This is called an eccentric muscle contraction. Often, a patient will feel a painful pull or pop in the back of the upper thigh. Bruising, swelling and weakness may accompany this injury.

In the initial stages it is important to rest, ice, compress and elevate the leg (RICE). But due to the high reoccurrence rate it may be necessary to seek further treatment to prevent further injury. The three most common deficits that contribute to reinjury are persistent weakness, decreased tissue extensibility/stretch due to scar tissue, and altered motor planning during sport. Physical therapy can help to identify and eliminate these deficits. Stretching alone is not the answer.

Due to the mechanism of injury with most hamstring strains (eccentric contraction), it is important to train and strengthen a muscle eccentrically so that it can remodel and protect itself. More and more research suggests that these exercises can minimize the risk of reinjury; therefore, they are one important component of treatment. A few examples of eccentric exercises can be found at http://links.lww.com/SCJ/A8, but a physical therapist should be consulted to assist with proper technique and to ensure proper exercise progression.

Hiederscheit BC, Sherry MA, Slider A, Chumanov ES, Thelen DG. Hamstring Strain Injuries: Recommendation and Injury Prevention. J. Orthop Sports Phys. Ther.2010;40(2):67-81.

Sherry MA, Best TM, Slider A, Thelen, Heiderscheit BC. Hamstring strains: basic science and research application for preventing the recurrent Injury. Strength Cond J. 2011;33(3): 56-71

By Nancy Mason

The first day of fall arrives September 23, 2011. That same day also celebrates the observance of the National Falls Prevention Awareness Day. This day was designed to promote and increase public awareness about how to prevent and reduce falls among older adults.

Are you aware that one out of three adults age 65 and older fall every year? Falls and fall related injuries are among the most serious and common medical complaints expressed by older adults. Most fractures among those 65 and older are caused by falls, and among that age group, falls are the leading cause of injury death. However, even if someone falls and is not injured, he or she often develops a fear of falling. And fear of falling can cause people to limit their activities, leading to decreased mobility and a loss of physical fitness, which in turn actually increases their risk of falling!

So why does our risk of falling get worse as we age? Most studies cite reasons such as changes in balance, vision, reduced muscle strength, slower reflexes, decreased flexibility, various medications and illness. Some medications can make you feel dizzy or confused, or weaken your muscles. These include blood pressure pills, heart medications, water pills, sleeping pills and anti-depressants. Standing up too fast, causing a rapid drop in blood pressure and a feeling of lightheadedness, can make you trip and stumble the first few feet out of the chair or bed. Drinking alcohol can also lead to falls as it can slow reflexes, causing you to feel sleepy or confused or alter your balance or judgment, causing you to take risks that may cause you to fall. One more reason people fall is they trip or slip due to loss of footing or traction.

But for all the reasons your balance may decrease, it is not a lost cause. You can take steps to decrease your risk of falling.

1. Talk to your doctor. There may be a physical reason that can be addressed and corrected.
2. Talk to your family. It is interesting that often this is avoided, for fear you will be scrutinized and perhaps deemed unable to live alone. But think about it: Who better to help make your home more safe for you to live in than your family?
3. Assess your home for trip hazards.
   • Remove objects including magazines, newspapers, phone cords and extension cords from walkways.
   • Make sure all rugs are secure with slip-resistant backing and remove all loose or frayed rugs.
   • Clean up spills quickly.
   • Be sure all stairs are well lit and use proper lighting at night to guide the way to the bathroom.
   • Have handrails installed on all stairs and use properly installed grab bars near the tub and shower.
   • Don't let your cat or dog trip you. Know where your pet is whenever you are standing or walking.
4. Steady your gait by wearing proper footwear and using walking sticks, canes or walkers as needed. Wear non-skid, rubber soled, low-heeled shoes that support and fit your feet. Avoid wearing slippers without tread on tile, hard wood floors or linoleum. Maybe "slippers" are called that for a reason!
5. Have your eyes checked. You want to be able to see steps, variations of floor depths or surfaces, and cracks or bumps in sidewalks.
6. Stay active and exercise regularly. It's important to include exercise that focuses on strengthening your legs, maintains flexibility and works on balance. Classes such as tai chi, Matter of BalanceTM and EnhanceFitnessTM can be found in the community through groups like Senior Neighbors, Area Agency on Aging, Spectrum Health, The Y, etc. It is often easier to stick with your exercise program if you work out with a friend or in a class.

Falling happens. But you CAN reduce your risk of having it happen to you. If you are falling, or have decreased your activity level due to a fear of falling, take action now. Perhaps you are already active and engaged in regular exercise. Try adding a few more balance activities to your routine. If you are not exercising routinely, try convincing someone to work out with you. Maybe start with a good walk every day. If you do not know what to do, or feel unsteady or unsafe, seeing a physical therapist may be of benefit. Keeping yourself strong and steady can help you stay independent. It is worth the effort.

Nancy Mason is a licensed physical therapist at the West Pavilion Spectrum Health location. With a passion for fall prevention, Nancy is a member of a "successful aging" committee comprised of representatives from Senior Neighbors, the Area Agency on Aging, Spectrum Health's Healthier Communities, Priority Health, and other local community senior advocate agencies, working to impact the number of falls in Kent county. In addition, Nancy teaches community classes through Spectrum Health's Healthier Communities Better Bone and Balance program, including posture retraining, fall prevention and A Matter of Balance R which is a national efficacy based program that addresses the fear of falling. She received her Bachelor of Science and physical therapy training at the University of Michigan and a Master in Management from Aquinas College.

For more information:

• Centers for Disease Control and Prevention
• National Institute on Aging Information Center (or  call 800.222.2225)
• NIHSeniorHealth (www.nihseniorhealth.gov)
• National Institute of Arthritis and Musculoskeletal and Skin Disease
• Your local Senior Neighbors or Area Agency on Aging

Dave George


Whether you are a serious bicyclist or a recreational rider, when it comes to cycling, you and your bike should fit well together. A proper bike fit minimizes discomfort, increases efficiency and helps prevent pain and injury. Physical therapists can evaluate the way your body is positioned on the bike to make sure that your biking style "fits" your functional goals, whether they are for comfort and endurance or for speed and performance.

Our physical therapists want you to know that your own physical fitness is equally important to the way you and your bike fit. Good flexibility and balance between the hamstrings, quadriceps and gluteal muscles is crucial because they generate the majority of the pedaling forces and experience high frequency stress during the pedaling motion. Proper stretching, balance and strengthening exercises will help improve the efficiency of skills such as pedaling and maneuvering the bicycle in addition to allowing the rider to enjoy the sport in comfort.

Common Bicycling Pains

• Anterior (Front) Knee Pain. Possible causes: Saddle too low, pedaling at a low cadence, using your quadriceps muscles too much, misaligned cleat for those who use clipless pedals, muscle imbalance in your legs (strong quadriceps and weak hamstrings).
• Neck Pain. Possible causes: Handlebar too low, too far away, or too close. A saddle with excessive downward tilt also can be a source of neck pain.
• Lower Back Pain. Possible causes: Poor hamstring flexibility, low cadence, using your quadriceps muscles too much, poor back strength, handlebars that are too far away or too close.
• Hamstring Tendinitis/Posterior Knee Pain. Possible causes: Poor hamstring flexibility, high saddle, misaligned cleat, poor hamstring strength.
• Hand Numbness or Pain. Possible causes: Handlebars located too close, poorly placed brake levers, downward tilt of the saddle.
• Foot Numbness or Pain. Possible causes: Using quadriceps muscles too much in pedaling, low cadence, faulty foot mechanics, misaligned cleat.
• IlioTibial Band Tendinitis / Lateral Knee Pain. Possible causes: Saddle too high, leg length difference, poor flexibility, poor cleat alignment.

Dave George is a member of the Rapid Wheelmen and Michigan Mountain Bike Association. He participates in many long distance bike tours, and competes in cyclocross and mountain bike events, such as Barry-Roubaix, Lumberjack 100, and The Iceman Cometh. Dave is a physical therapist at the Rockford clinic located in the MVP Healthclub.

Sue Gunnink

Many athletes wonder if a sports drink is necessary for optimum performance. The sports drink I get the most questions about is the Gatorade product line. Gatorade has many products on the market and it can be difficult to decipher which may be best for the athlete. The three main product lines are the G Series, G Series Fit, and G Series Pro. For this blog, we will focus on the G Series line, which is appropriate for a majority of athletes. We will look at if the research supports the claims made from a nutrition and performance standpoint.

The first component of the G Series line is 01 Prime, designed to be used before exercise or competition. 01 Prime is made up of concentrated carbohydrate and B-vitamins in a 4-ounce package. The athlete is supposed to take it 15 minutes prior to exercise with the purpose of sending concentrated carbohydrate to muscles as an energy source and providing specific B-vitamins that aid in energy metabolism. Phillips et al found that the consumption of carbohydrate prior to exercise and competition does improve performance by delaying time to exhaustion. So why not just take one of the new energy drinks (Red Bull, Monster, etc.) as a source of carbohydrates and B-vitamins? The biggest difference is the addition of caffeine in those products. 01 Prime from Gatorade contains no caffeine, which can cause jittery side effects in some athletes. Also, the serving size of 4 ounces is appropriate for performance in that it will not make the athlete feel full and delay the absorption of the carbohydrate and vitamins.

While athletes exercise or compete, they use up energy stores within their muscles. It is important to replace this energy to sustain the level of performance desired. After the athlete begins exercising, the G Series shifts to 02 Perform. This was designed to meet the athlete's calorie and carbohydrate needs to support moving muscles. Depending on the duration of the activity, the athlete has two options-the original G 02 Perform and lower calorie G2 02 Perform. Athletes whose workouts and competitions are longer than 60 minutes may choose to drink the original G 02 Perform due to the higher carbohydrate content (14 grams per 8 ounce serving). The higher carbohydrate content replenishes the energy lost in the longer competitions. The lower calorie G2 02 Perform (5 grams of carbohydrate per 8 oz serving) is geared toward shorter duration (less than 60 minutes) or a lower intensity workout. This option could also be considered for the athlete with a high sweat rate who needs to consume large volumes of fluid (more than 34 ounces of fluid per hour) but who does not need the extra carbohydrates. Appropriately, the G2 series has removed the vitamins and focuses on enhancing performance through hydration, appropriate energy and electrolyte replacement. This philosophy means a sports drink like G 02 Perform (or G2 02 Perform) is better than water.

Research is showing that within 30 to 60 minutes after physical activity, the athlete should consider a carbohydrate and protein replacement. G 03 Recover is designed for this purpose. It supports muscle recovery and helps athletes transition to their next workout or competition. G 03 Recover is composed of 8 grams of protein, 7 grams of carbohydrate (60 calories), 120 mg sodium and 45 milligrams of potassium in an 8 ounce serving. These ingredients replace electrolytes lost during activity. Even the type of protein was considered when choosing whey protein. Wilkinson et al found post-consumption of milk, specifically the whey protein found in milk, promotes the building of muscle following exercise. G 03 Recover is not a standard protein recovery shake. It has the consistency of a sports drink similar to the original G 02 Perform (or G2). This may be more appealing to some athletes following a workout/competition due to individual tolerances post exercise.

From a nutrition and performance standpoint, Gatorade G Series does seem to have the research and philosophy to support using its products. Water is appropriate for leisure activity. However, for athletes looking to improve or maintain their performance, using Gatorade G Series is an option.

Sue Gunnink is a registered dietitian specializing in sports nutrition at Spectrum Health Butterworth Hospital. She is a certified specialist in sports dietetics (CSSD). She received a Bachelor of Science in dietetics from Eastern Michigan University and a Master of Science in human nutrition from Michigan State University. Her thesis examined the fruit and vegetable intake of Division I college football players. She is also part of Specialists Championing Optimal Performance & Education (SCOPE).

References:

Phillips et al. Carbohydrate ingestion during team game exercise: current knowledge and areas for future investigation. Sports Med 2011; 41(7)559-85.

Wilkinson SB et al. Consumption of fluid skim milk promotes greater muscle protein accretion after resistance exercise than does consumption of an isonitrogenous and isoenergetic soy-protein beverage. Am J Clin Nutr 2007; 85: 1031-40.

Gatorade. G Series.

Did you know that a large football player can lose up to 15 pounds of water in a single practice session? It is not uncommon for an athlete to sweat 1-2 liters per hour on a hot day, and most athletes drink far less than they sweat because they underestimate their sweat loss.

As summer training camps and the grueling two-a-day practices begin, we cannot afford to forget about the importance of hydration while playing sports, especially in hot humid weather. When athletes (particularly runners and football players) participate in vigorous exercise during these warm months dehydration can become fatal. Exertional heatstroke is a leading cause of preventable non-traumatic exertional sudden death for young athletes in the U.S. (CDC)

Dehydration is dangerous and can occur when the body loses as little as 2 percent of its body weight in water. When excessive water is lost, the cardiovascular and thermoregulatory systems are placed under severe stress and these systems become overwhelmed and fail the athlete. Many physiological strains occur to the dehydrated athlete including a decrease in aerobic performance, decreased mental/cognitive performance and it can lead to organ failure. Some early signs and symptoms of dehydration and heat exhaustion include dry mouth, concentrated urine, lethargy, constipation, nausea, dizziness and lightheadedness. A loss of salt occurs in conjunction with water loss causing an electrolyte imbalance which can lead to excessive muscle cramping.

If dehydration continues, the body is no longer able to maintain homeostasis leading to heatstroke which can lead to impaired cardiovascular function and neurological failure. It is essential that heatstroke is diagnosed and treated early because the central nervous system will become impaired. An athlete may present with agitation and confusion and may be unable to maintain balance.

In a 2009 consensus statement, the National Athletic Trainer's Association (NATA), reviewed new guidelines for preseason heat-acclimatization. This 14-day program is aimed at enhancing exercise heat tolerance and the ability to exercise safely and effectively in warm to hot climates. The initial 3-5 days of summer practices are the most important for progressive acclimatization as most heat-stroke deaths occur on day 1 or 2 of two-a-day practices. More heat-acclimatization guidelines can be found at the National Athletic Trainers' Association website.

Careful considerations by the coaches and athletic training staff must be made to limit practice durations, allow adequate cooling breaks, hold practice in the coolest parts of the day, and provide a gradual introduction of protective equipment/uniform. Athletes and parents should be aware of the signs and symptoms of dehydration and should maintain proper hydration before, during and after sporting activities. By the time an individual senses thirst, his/her body may have already lost more than 1 percent of his/her total water amount; therefore, thirst is not a good indicator of dehydration. In addition, electrolytes are lost with sweat and will need to be replenished as well. Sports drinks enhanced with electrolytes are a good way to offset electrolyte loss. The American Academy of Sports Medicine has put out some hydration guidelines and these can be found at the American College of Sports Medicine website.

Casa, DJ, Csillan D. Preseason Heat-Acclimatization Guideline for Secondary School Athletics. J Athl Train. 2009;44(3):332-333.

Centers for Disease Control and Prevention (CDC). Heat illness among high school athletes - United States, 2005-2009. MMWR Morb Moratl Wkly Rep. 2010 Aug 20:59(32);1009-13.

Swaka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Satchenfeld NS. American College of Sports Medicine position stand. Exercise and Fluid Replacement. Med Sci Sports Exerc. 2007:377-387.

While I love to play the game of golf I have recognized that years of swinging a softball bat and the game of golf don't always combine too well. Nonetheless, I find golf an awesome opportunity to stay active and competitive. I agree with Paul Harvey who said, "Golf is a game in which you yell ‘Fore!,' shoot six and write down five."

Although golf is a low impact sport, it demands physical fitness and preconditioning. It is a sport that is played by individuals of all skill level and all ages. Because of this, injury is common. Golf is a sport that satisfies the surgeon general's recommendation of low-intensity exercise for physical fitness, but it does carry a high annual injury rate of 40 percent among amateurs. (Brandon) Overuse injuries are more common in elite players, while amateurs are more frequently injured from poor swing technique and lack of physical conditioning. While experience changes the type of injury, low back pain is the most frequently reported (Reed), and professional golfers have the highest incidence of back injury among all professional athletes (Watkins).

Most back pain begins gradually, is usually localized, and is often associated with muscle tightness or spasm.

During the modern golf swing, spinal compression forces can reach up to eight times an individual's body weight. (Gluck) This amount of force is almost equivalent to a football lineman hitting a sled. With that amount of force going through the spine repetitively, it is no wonder why the spine is susceptible to injury. In addition to compression, there is a considerable amount of twisting and torsion of the spine. Joint, muscle and disc irritation are common causes of pain. Individuals who have pain can be coached to swing around a stable spine to help decrease pain and minimize injury.

Increased stress to the low back also occurs if there is inflexibility or weakness in the joints around the lumbar spine. Frequently, hip tightness (particularly in the lead leg), can cause increased stress at the low back because the lumbar spine has to increase its rotation to make up for tightness within the hip. (Vad) The body will always find a way to move and it will alter normal swing mechanics to accommodate for limitations. A physical therapist can help identify these limitations and provide exercises to eliminate these deficits. Swing modifications can be made to decrease the stress on the injured structures and allow them to heal.

Stretching is also an important component of injury prevention. Taking a brisk walk prior to stretching may assist in warming up the muscles. While there are many beneficial stretches, one general stretch that can affect the shoulders, hip, and low back involves mimicking your golf swing. Grip the club horizontally in front of your body and then move toward the backswing motion and follow through, holding each end range position for 30 seconds. Perform two or three repetitions. After stretching, I recommend warm-up swings. Start with short irons and work toward the longer irons and drivers.

Using a proper stretching and warm-up routine has been found to help decrease injury in golfers. Sue Carpenter, PT and Florence Kendall PT, FAPTA have written a book titled, "Golfers: Take Care of Your Back." This book discusses stretching and warm-up activities, strengthening and posturing tips to help stay in shape and decrease the chance of injury. It is advisable that avid golfers and golfers who play year-round adopt a training program that focuses on not only flexibility and strength but conditioning as well.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and treatment.

SOURCES:
Brandon B, Pearce PZ. Training to prevent golf injury. Curr Sports Med Rep. 2009;8(3):142-146.

Gluck GS, Bendo JA, Spivak JM. The lumbar spine and low back pain in golf: a literature review of swing biomechanics and injury prevention. Spine J. 2008;8:778-788.

Reed JJ, Wadsworth LT. Lower back pain in golf: a review. Curr Sports Med Rep. 2010;9(1):57-59.

Vad VB, Bhat AL, Basrai D, et al. Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits. Am J Sports Med. 2004, 32:494-497.

Wadsworth LT. When golf hurts: musculoskeletal problems common to golfers. Curr Sports Med Rep. 2007;6(6):362-365.

Watkins RG. Lumbar disc injury in the athlete. Clin Sports Med. 1996;15:37-53.

For years we all have heard about the detrimental effects of cigarette smoking on your lungs, heart and blood vessels. But smoking and my shoulder? How are they related? A group of orthopedic researchers in St. Louis published an article in 2006 regarding the effects of nicotine exposure on rats and the delay in tendon to bone healing following rotator cuff surgery. The study illustrated that rats exposed to nicotine following rotator cuff surgery (yes, rats have rotator cuffs) had more inflammation and the inflammation cycle persisted a longer duration in the shoulder joint. Inflammation delays healing and causes persistent pain. This study also showed that the rats exposed to nicotine had less cellular proliferation and collagen production. When an injury occurs, cell proliferation is necessary to facilitate healing and collagen forms the junction between tendon and bone. The rotator cuff naturally has a poor blood supply and so its natural healing process is less than desirable even for the non-smoker. When you add nicotine to the situation, the healing quality is diminished significantly. The study also illustrated that the nicotine exposed rats produced less type-I collagen and had weaker shoulder joints when exposed to physical stress and strain to the tissue. The rotator cuff is a group of four muscles with tendons that attach in the shoulder and are essential for proper lifting of the arm overhead. A rotator cuff injury is a very common orthopedic injury and most of us know of someone who has had a rotator cuff tear requiring surgery and subsequently a long, painful recovery. Smoking can hamper the healing process and possibly limit the overall functional outcome and ability to use the arm following surgery.

A more recent study published in 2010 also noted increased risk for rotator cuff tears in patients who smoke. The orthopedic researchers administered a questionnaire to 586 consecutive patients who presented with shoulder pain with various questions including the patients' smoking status, duration of smoking and number of packs per day smoked. The researchers found a strong association between smoking and an increased risk of rotator cuff tears. There was a dose-dependent and time-dependent relationship between smoking and rotator cuff tears also. The more you smoke each day and the longer you have smoked both play a role into the increase risk of a rotator cuff tear.

Smoking is proving to be detrimental to muscle and tendons as well as heart, lungs and blood vessels. It is another great reason to quit smoking for the health of your shoulders.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and treatment.

Barefoot running is the newest craze in the running world. It seems to be becoming more popular. Now, we're seeing athletic shoe companies coming out with many new types of shoes to simulate barefoot running.

Actually, it's not a brand new concept. Barefoot running was first seen in competition in the 1960 Olympic marathon. The story goes that Adidas was the official shoe sponsor for the 1960 Olympics, and they didn't have any shoes that would fit an Ethiopian athlete named Abebe Bikila. So he ran the marathon barefoot. He was used to barefoot running since that was the only way he had ever run in all his training.

Guess what? He won the 1960 Olympic marathon. Barefoot running really didn't take off at that time because of the development of the official "running" shoe by Nike and many other companies in the early 1970s. The athletic shoe industry has dominated the shoe world, and years of research and marketing has made the running shoe industry what it is today.

Those same companies are now coming out with very flexible running shoes that basically just cover the foot to protect it from the running surface. Some of these shoes include the Vibram Five Fingers, Merrell Trail Glove and the Nike Free. All these shoes tout that they recreate the natural feel of running barefoot and allow the same mechanics of running that are visualized with barefoot running.

The recent resurgence of barefoot running can probably be attributed to Christopher McDougall and his book, Born to Run, published in 2009. In the book, the author discusses his research into many African tribes and how those runners stay injury free with no shoes.

Yet our culture promotes runners using $150 shoes. And an avid runner is usually struggling with some type of lower extremity injury on a regular basis. The book is definitely worth the read and it will certainly challenge your current thoughts on running.

There are two schools of thought on barefoot running. Each group feels passionately about its stance. The proponents of barefoot running believe heavily in the prevention of injury aspect and the improved efficiency of running. Then there is the traditional group that states shoes are necessary and the foot needs stability and support when running repetitively.

There has been a tremendous amount of research put into the making of the current running shoe. Each type of shoe is made for a different type of foot. In opposition, the barefoot group believes in no shoes, and that this works for all types of feet.

A review of the medical research in peer reviewed journals does not reveal any studies that support the injury prevention aspect. The biomechanical research does illustrate that barefoot running leads to more running on the ball of the foot, which reduces the forces of impact, shortens the stride length, lessens foot contact time and increases the stride frequency.

You can watch videos about this comparison on YouTube, particularly the studies performed at a Harvard University biomechanics lab.

Barefoot running has been shown to change running biomechanics. Is this change good for every runner? Probably not. Our physical therapy clinic has seen some overuse injuries by lesser skilled runners who tried barefoot running because it's the new trend, and because it's touted as the best way to prevent injuries.

My opinion is that if you are a naturally skilled runner who has been running since your high school days, you may be able to handle the barefoot running concept. And you may find it helps put you over the top for efficiency and speed.

But if you are like most people who take up running in their 30s or 40s as a weight loss tool, or you just want to get back in shape, your running biomechanics and general leg strength may not support the barefoot running concept, and you may become injured.

There is definitely not enough research to make a sound argument for or against the concept of barefoot running. Barefoot running will probably run its course like other exercise fads. Yes, some people are born to run barefoot, but many of us are not.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.

Many high school athletes are now finalizing their off-to-college plans. They're figuring out how much scholarship money they got, what NCAA division the university is, and what it all means.

It's time for everyone to have a reality check-especially parents who have driven their kids to multiple sports camps, sports performance training facilities, elite travel teams and tournaments across the country.

When you factor in the financial commitment for all the travel, team memberships, equipment and uniforms from the age of 10 to 18 for each of your children, you will be lucky if you break even financially. And that's if your child gets a full scholarship for four years.

What are the chances that your kid will get athletic scholarship money? According to the National Collegiate Athletic Association, ice hockey has the best odds. About 13 percent of these high school athletes get athletic scholarship money for college. That's because there are fewer high school ice hockey players compared with other sports, with many high schools not even offering ice hockey.

The next easiest sport is actually football. One in 17 high school athletes go on to receive money for playing football in college. Of the 5.8 percent of football players receiving college scholarship money, only 1.7 percent of those football players will play at the professional level.

The hardest sport for scholarship money is basketball. About 3 percent of boys and girls receive money to play at Division I, II, or III universities and only 1 percent make it at the professional level.

It may sound like I'm anti-sports for youngsters and adolescents. Absolutely not. I was a high school and college athlete myself, and I can attest to the great benefits-both mental and physical-of organized sports. There is nothing like being part of a team and working hard to accomplish goals.

What does concern me is the over-emphasis of our society on pushing kids harder at an earlier age. Kids are pushed to pick one sport and do that sport year-round, honing those skills. There really is no "off season" in any sport. If you excel in soccer, for example, you play year round, indoor and outdoor.

As a physical therapist specializing in sports, I see many young athletes with overuse injuries from training year round and performing the same sports skills over and over again. One question I am asked by parents is "When should my child be lifting weights?" To reap the benefits of weight lifting, your child needs to be at least starting puberty and developing physically. Testosterone and estrogen are needed to develop strength and muscle mass.

Weight lifting prior to puberty is just asking for trouble with undue stress put on weaker body structures. Adolescents need time to rest their bodies and recharge the system both physically and mentally.

If you're looking for more information, check out stopsportsinjuries.org. This website focuses on injury prevention for youth and adolescent athletes. It's a great resource for coaches and parents (most of them coach their kids' teams at one time or another). The take-home point here is that it's OK for your child to take time off from organized sports and be a kid for a little while. I highly doubt it will hurt your child's odds of playing in the NFL.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.

Tennis elbow (lateral epicondylitis) is one of the most common overuse ailments in the upper extremity. This nagging condition produces pain on the outside of the elbow. This is the spot where the forearm's extensor tendons (tendons which extend the wrist) become inflamed.

Tennis elbow was named for the high volume of amateur tennis players who received overuse injuries from poor technique. But more often, these injuries are associated with gripping and rotating the forearm during activities like carpentry, construction, computer work, factory work and sporting activities.

It's crucial that treatment starts when the symptoms are in their earliest stages. This condition can turn into a chronic pain (lateral epicondylosis), making the recovery time much longer than necessary.

During the initial stages, rest and ice are appropriate. Although these injuries are often related to overuse, there may be some underlying strength and flexibility problems that contribute. Tightness and weakness in the muscles of the forearm can contribute to increased stress where the tendon inserts into the bone, and this can lead to inflammation.

Studies have found that elbow braces (straps and sleeves) can increase a patient's ability to grip harder with less pain.1 Using these braces is common. The goal is to reduce the tendon's stress, thereby decreasing the inflammation.

Using a brace in combination with rest, ice and joint protection strategies can decrease the pain enough to move into the strengthening and flexibility phases of treatment.

A physical therapist can prescribe exercises to increase flexibility of the extensor tendons, as well as exercises for strengthening.

Often, exercises that emphasize strength while the muscle is lengthened and stretched (known as eccentric exercises) can facilitate healing. While weights are commonly used, there is a new tool called the Thera-Bandâ FlexBarâ, which also can facilitate this type of strengthening.2

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.

¹Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patient with lateral epicondylosis. J Orthop Sports Phys Ther. 2009;39(6):484-9.

²Tyler TF, Thomas GC, Nickolas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg. 2010;19(6):917-22.

The phrase “No pain, no gain” might seem true when we talk about pain after a long run or a tough athletic competition. But when it comes to injury and recovery, it can be detrimental.

Within our practice, we often see those “crazy” marathon runners who train, train and train some more. They usually come into the clinic with hip, knee or ankle pain and wonder if it’s okay to keep running through the pain. Sports Injuries like Achilles tendonitis, IT band syndrome, plantar fasciitis or shin splints can sideline these athletes for much longer if the injuries are not dealt with properly.

These athletes are passionate about their training and not much can get in their way. Here’s the advice I offer a runner who has pain and wonders if it’s okay to run: they can run through the pain as long as the pain improves as the run continues. A run should be stopped if the pain worsens, and the pain should not become worse after running.

Pain is the body’s natural defense mechanism. It’s telling you that there is too much stress on the structure involved. So if you live by the saying “no pain, no gain” and are nursing an injury, you may struggle longer than you have to. Listen to your body. It’s telling you what you need to do.

You may need to work with a physical therapist to identify muscle imbalance, alignment issues, footwear considerations or training errors that may contribute to these overuse injuries.

The good news is that cross training is an important component of injury recovery. Swimming, cycling, and elliptical training can be beneficial because they reduce or eliminate impact while maintaining a cardiovascular challenge. And they can alleviate some of that “I can’t run” frustration until you’re back where you want to be.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and treatment.

Back pain is one of the most prevalent problems we face. In fact, it’s so common that it’s considered normal to have back pain at some point in your life. But for those who suffer from it, back pain is anything but normal and it can affect every aspect of our daily living.

While one may think that there should always be a reason for back pain, 60 percent of people develop pain for no apparent reason, according to research cited in Robin McKenzie’s book. He’s the creator of the well known McKenzie Method of physical therapy, and author of “The Lumbar Spine: Mechanical Diagnosis & Therapy.”

For most people, back pain will resolve by itself, and it’s estimated that 80 percent to 90 percent will recover in about six weeks, according to McKenzie. Physical therapy can hasten the recovery process by identifying patterns of movement or postures that may contribute to the pain.

It’s not surprising that in a majority of cases, low back pain is related to bending (flexion) positions. From the moment we wake in the morning we start to bend. Whether it’s to brush our teeth, put socks on, sit to eat breakfast, drive to work, relax in a cushy recliner or care for small infants—we bend a lot. In fact, I have heard that on average we bend 3,000 to 5,000 times per day.

While we can try to eliminate some of this bending, it’s inevitable that we all have to sit at some point, and sitting is a flexed position. Posture management is a significant contributor to recovering from low back pain. Clinically, I have found that the use of a lumbar roll for low back support may prove to be one of the single best tools to help minimize spinal flexion in sitting and encourage the spine to be more upright.

I usually recommend rolling a towel until it has about a 3- to 5-inch diameter and placing it in the small of the back at the level of your waistline. Allow the roll to support the back, but do not bend back over it.

While this is by no means a cure, it can decrease pain and be a great starting point for someone suffering from back pain. If we can start to eliminate some of the mechanical forces that create low back pain, we can accelerate recovery. Start simple: Posture can make a huge difference.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and treatment.

SOURCE: McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis & Therapy. Waikanae, New Zeeland: Spinal Publications New Zeeland; 2003.

Osteoarthritis (OA) is one of the most common musculoskeletal disorders and one of the leading causes of pain and disability in the U.S. OA occurs when the cartilage in the joint wears down and creates inflammation. People with OA suffer from joint aching, pain with overuse as well as underuse, and intermittent swelling.

Most people over the age of 60 have some degree of OA. There is no known cure. Physical therapy can increase range of motion, flexibility, joint stability, strength and aerobic endurance. Through this, a patient’s pain may decrease and daily activities may get easier.

Because of the devastating affects of OA, patients often look for alternative solutions. I am frequently asked about supplements such as glucosamine and chondroitin. I usually tell my patients that these supplements are safe, but the research is conflicting regarding their effectiveness. As always, make sure you to talk with your doctor before you begin to take any supplements.

Glucosamine is a molecule used in the formation and repair of cartilage. Chondroitin has properties that increase the compressive resistance of cartilage. The theory behind using the supplements is to increase the availability of these building blocks within the joint.

Research does not always support this. A recently published meta-analysis revealed that the supplement does not affect joint space narrowing or joint pain. However, another published meta-analysis found that if taken daily, glucosamine and chondroitin may delay the progression of OA for two or three years.

Despite the conflicting results, there is enough research to support the safety of these supplements. There are several studies that have reported positive effects regarding joint pain. We cannot minimize the fact that these supplements have helped many individuals and that clinically, patients have reported good results.

At the end of the day, it is my opinion that if there is a chance these supplements work and do not cause harm, it may be worth a shot. The consensus within the research is that best results may take several months to occur, so if you choose to take it, you may need to be patient.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.

SOURCES:
Wandel S et al. Effect of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. BMJ. 2010 Sep 16;341:c4675.

Lee YH, Woo JH, Choi SJ, Ji JD, Song GG. Effect of glucosamine or chondroitin sulfate on osteoarthritis progression: a meta-analysis. Rheumatol Int. 2010 Jan;30(3):357-63.

Pedometers are a great way to kick off a new exercise plan because they’re easy to use and affordable. Exercise can seem overwhelming to some, but walking is a great way to get moving, and it has multiple health benefits. In addition to weight management, walking for exercise can decrease blood pressure, decrease cholesterol, and decrease the risk of type 2 Diabetes.

Pedometers have been studied among many different populations, including people with knee arthritis, diabetes and even cancer survivors. These small devices have been found to increase walking behavior and increase an adult’s number of steps per day.

While pedometers do not always calculate correct distance because of changes in step length, they are great tools that give immediate feedback. They also can motivate you, increase self-awareness and help you set realistic goals.

So how many steps are enough? In a 2004 study conducted by C. Tudor-Locke and D.R. Bassett Jr., a step index was developed. Here’s what they found:

The American College of Sports Medicine recommends that every individual perform at least 30 minutes of moderately intense cardiovascular activity at least five days a week. Thus, a goal for an “active” individual would be 10,000 to 12,500 steps per day.

When beginning any exercise program, it’s important to make obtainable goals. I recommend taking a couple of days to figure out how many steps you take on a “typical” day. This will determine your starting point and enable you to add 500 to 1,000 steps per day. You can increase your daily steps weekly or bi-weekly, depending on your progress. Any number above your “typical” amount is a good start!

Here are a few suggestions to get you walking those extra steps and achieving your fitness goals:

• Park further away
• Take the stairs instead of the elevator
• Walk the dog for a longer duration
• Spend time with your family strolling at the mall or in a park
• America on the Move is a free website which claims that it can help you track your walking progress on a virtual trail.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.

This phrase has been used in the sports world for years-and many people believe that the “right” shoe can make them run faster and jump higher.

The most recent trend in athletic shoes is the rocker bottom shoe, with its many claimed benefits. In reality, the rocker bottom shoe has been around the medical community for years. It’s been used for patients with diabetes for pressure sores and other neuromuscular disease that impair the muscles from working efficiently.

The rocker bottom helps roll the foot forward from the heel strike to the push off phase of the walking cycle. This design also changes the standing and walking posture of the body. Research has shown that there is a decrease in trunk and hip flexing, which translates into standing more upright during weight-bearing activities.

The Masai Barefoot Technology (MBT) company from Switzerland was one of the first mainstream shoe companies to promote this technology for the average consumer. They call their product the “anti-shoe,” referring to the curved surface.

The proposed benefits of such a shoe include improved posture with walking and standing and increased muscle activation of the hamstring and gluteal muscles with activity, and burning more calories because all the muscles of the lower leg are working to keep you centered over the shoe. It also is supposed to decrease hip and knee joint compression, and thus decrease pain from osteoarthritis. There has been research conducted to substantiate these claims.

Can these shoes really be that good? I asked this question for months as I researched this subject. The shoes are costly, so I didn’t just run out and buy a pair to try them. Finally, I gave in and purchased a pair of MBT shoes in a quest to cure my own Achilles tendonitis. All I can say is, “Why did I wait so long to buy them?”

They have helped my Achilles tendonitis significantly and yes, I did feel my posture improve and my hamstring and gluteal muscles get a great workout and increase in strength. I wear my MBT shoes every day at work and the shoes have helped me.

I have had some patients who have tried them and found them to be too unstable and difficult to get used to. They are not the answer for everyone, but for me they are worth every penny.

MBT is the original company selling these type of shoes, and now Skechers and Reebok carry similar styles. The rocker bottom shoe is really only designed for walking, and not sports like running or basketball. It is worth checking them out and at least trying them on in the store.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.

Do you have ankle or foot pain and have been told you have flat feet? If you do, you are probably like so many people searching for the right shoe or orthotic.

When the foot hits the ground, there is a chain reaction of events that transmit forces from the foot all the way up the leg and through the trunk. This means all the muscles up the leg can influence the foot.

If you have flat feet and you don’t believe your butt plays an important role in the health of your feet, I challenge you to perform this simple task:

1. Stand with feet hip width apart.
2. Allow your arches to flatten out like a pancake. Pretty easy to do, right? You probably live here on a daily basis.
3. Now, try and create an arch in standing by rolling slightly to the outside of your feet.
4. Tighten your buttocks as forcefully as you can.
5. With your buttocks tight, try and let your arches flatten out. Not nearly as easy. In fact, it is almost impossible-am I correct?

This simple task demonstrates the role of the butt in maintaining alignment of the feet. The next time you are thinking of a quick fix to foot and ankle pain, take a step back and think about that potentially weak butt.

While orthotics may provide short term pain relief and improved alignment, a long term solution may include strengthening of the entire lower extremity. Single leg activities with emphasis on maintaining good hip, knee and ankle alignment would be beneficial. A focus on tightening the glute (butt) muscles during these activities is encouraged.

Often, this can help you improve alignment and muscular balance and keep those feet functioning in the long run.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.

Even though I’m a physical therapist, I’m often the worst at following my own advice. About two years ago I had a serious ankle sprain when I jumped down three steps.

The first step in my recovery was an X-ray to rule out a fracture. No fracture was found, and I was sent home on crutches with an air cast and instructions to ice, elevate and rest the ankle. These instructions are given to so many, but often times even a “simple” ankle sprain can cause a cascade of nasty side effects if not taken care of properly.

Even two years later, I find myself wishing I would’ve broken my ankle because it probably would have healed faster. It’s not unusual for people in this situation to have long lasting weakness, stiffness and even recurrent ankle sprains.

Understanding the phases of healing, and learning a few exercises and tips to hasten recovery, might help you avoid some of these long-term effects.

Inflammatory Phase (three to five days): Protect the ankle, control the swelling and perform gentle, pain-free movements. A brace may help during this phase. Depending on the severity of the sprain, crutches are often used.

Cell Proliferation (four to six weeks): During this phase, the body makes new tissue fibers, but these tissues are laid down in a disorganized manner. Therefore, it’s important to provide gentle forces that encourage the tissue to heal correctly.

Gentle physical activity should be started so that the scar tissue does not become inadvertently adhered to other tissues. One stretch that can facilitate ankle flexibility is the “runner’s stretch.” (Place one foot back and one foot forward. Lean into a wall until a stretch is felt in the calf of the back leg.) Be careful to push enough to get a stretch, but not so much to create pain that lingers.

Re-Modeling Phase (six months): During this phase, a continuation of stretching is needed to facilitate tissue healing, and it is important to restore the normal function of the ankle. The ligaments around the ankle can become stretched out, leading to instability.

How many times have you heard someone say they have “weak” ankles or that they sprain their ankles all the time? It’s important to increase balance, strength, and endurance of the muscles surrounding the foot. Working on single leg balance can help to do this.

Start by balancing on one leg on the floor. Then move to more challenging surfaces like a couch cushion, trampoline, or BOSU ball at the gym. This will help the muscles become more reactive and may decrease the likelihood of the rolling the ankle again.

Knowing the proper stages of an ankle sprain and what activities to do during the stages of healing may help prevent some of the harmful after effects. But if you are noticing prolonged stiffness or instability of the ankle, it may be beneficial to seek professional advice.

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.

Little leaguer’s elbow is an overuse condition seen in young baseball players, primarily pitchers. There are lots of possible causes for this condition:

• Throwing too hard
• Throwing too often
• Throwing an increased number of pitches per week
• Throwing too many curve balls at too young an age
• Changing to a league where the mound is elevated or further from home plate

Today, it seems that kids are more focused on single-sport participation, with year-round training at higher intensities. They start playing at younger ages, which increases the likelihood of an overuse injury

With Little Leaguer’s Elbow, the pain often is located on the inside of the elbow where a growth plate is present. When baseball players throw, there is a huge amount of tension that occurs on the inside of the elbow, which can cause increased inflammation. This usually occurs during the cocking and acceleration phases of pitching.

The repetition injures the growth plate, which is not as strong as the ligaments. This causes the growth plate to become inflamed, irritated and painful. It’s not OK to continue pitching at this time because it can become a more serious condition without proper rest and recovery.

Proper bone growth depends on the health of the growth plate. After resting for an adequate period of time to decrease pain and inflammation-which varies depending on the severity-an appropriate throwing program should be implemented. Pitch count and selection should be taken very seriously. Strength and flexibility imbalances should be addressed and alignment and poor throwing mechanics should be corrected.

The American Orthopaedic Society for Sports Medicine published “Prevention and Emergency Management of Youth Baseball and Softball Injuries.” This document provides helpful guidelines for the maximum number of pitches recommended by age, as well as age recommendations for learning pitches. It also provides a return to throwing program.

Here is some additional information you may find useful:

• Protecting Young Pitching Arms
• Youth Baseball Pitching Injuries

The content of this article is provided for informational purposes only and is not intended as medical advice. Please consult a physician regarding your specific medical condition, diagnosis and/or treatment.