Active Care

Foot Discrimination

Have you been a subject of foot discrimination?  Relegated to the “supportive” section of the shoe store?  Those who over-pronate or have “flat feet” have suffered from an injury prejudice that has stemmed from the belief that this foot type predisposes one to a variety of orthopedic problems.  It has been deemed such a structural defect that flat feet can disqualify one from military service.

Of course, pronation is a natural part of every running stride.  When the foot hits the ground it flattens and rolls inward or pronates as a means to partially absorb the force of the foot striking the ground.  In the past, scientists and medical professionals have been concerned with over or under-pronation during the running stride and have long believed that those groups are at higher risk of injury.

Taking the lead from this firmly held belief, the athletic shoe industry has been built on the premise that every shape of foot needs a specific shoe.  Generally these three types of shoe are the “cushioned” shoe for the high arched or under-pronated, “stability” for the neutral foot and the “motion-control” shoe for the more severely flat-footed or over-pronated.

But despite this conventional wisdom, and best efforts of the salesperson at the running shoe store, new science may liberate your shoe choices.

In a recent study published in the British Journal of Sports Medicine, novice runners with flat feet or high arched feet didn’t suffer from any greater rate of injury when they ran in a neutral shoe rather than a motion-control or cushioned shoe matched to their foot type.

In the study, researchers followed nearly a thousand novice runners with different foot types for a year.  Every participant in the study received the same neutral shoe, regardless of foot type, and a GPS monitor to track mileage.  The volunteers were able to run as much as they wanted and at whatever speed they wished.

The group of runners ended up covering over 200,000 miles over the one-year study period and suffered from 300 injuries. While nearly a third of the runners in the study suffered from an injury during the year, the study concluded that, “foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe.”  Contrary to widely held belief, the over or under pronators didn’t didn’t suffer from an increased rate of injury.  Notably, for those participants that amassed more than 600 miles of running, the neutral footed runners actually experienced more injuries than those with flat or highly arched feet.

This well designed out study supports earlier evidence reported in the same journal in which female runners were randomly assigned a neutral, cushioned or motion control shoe before commencing a 13-week half-marathon training program.  Surprisingly, those that wore the motion control shoe experienced the greatest number of injuries and runners of all foot types reported the greatest level of discomfort with the ultra-supportive shoe.

Additionally, a recent review study in the journal Gait and Posture concluded that flat feet were not associated with any increase in injury rate other than a mild association with flat feet and shin splints. In fact, several studies in the review suggested that flat feet might be protective against the development of lower-leg stress fractures.

Now while those with a history of leg or hip injury may need more support, those that don’t have any problems shouldn’t rush to buy a heavily supportive shoe based solely on foot type.  Comfort and fit are important factors and given the above research findings, should perhaps be given greater emphasis when choosing a running shoe.

Researchers now suggest that beginning runners put greater focus on those factors that seem to have a greater association with running injury, such as body mass, training volume and any history of previous injury.

The Athlete’s Body

The Olympics give us a fascinating look at the physical and athletic qualities of individuals who have achieved the top level of sport.  But how did these athletes reach that level of athletic performance?  One popular book has advocated the theory that excellence in any sport or activity requires 10,000 hours of practice.  But how much does genetics matter?  Does an athlete’s body adapt to years of repetition in the same sport or did the athlete find success because their body was suited for that particular sport?  For example, would Michael Phelps have been so successful if he trained as a runner from an early age?

The evidence would seem to point to the contrary; Michael Phelps’ physical and athletic make-up optimized his chances for swimming achievement.  Michael Phelps might have been a successful runner but chances are he would not have won 14 gold medals in two Olympic Games if he ran track.  Add 10,000 hours in the pool to extremely long arms, huge hands and flipper-like feet and you have the makings of an athlete that has reached the pinnacle of his sport.  Those same attributes wouldn’t be as valuable to a runner, with or without 10,000 hours of running.  Watching Charles Barkley play golf is evidence enough that greatness in one sport does not necessarily translate to excellence in all.

One physical quality that should be added to the list of attributes that will allow an individual to swim more successfully is the mobility of the shoulder joint.  Confirming this observation, a study in the Clinical Journal of Sports Medicine found that elite swimmers possessed a greater degree of shoulder mobility than recreational swimmers.   The authors concluded that this mobility was both acquired through years of swimming and was an inherent trait in those that competed at the elite level.

Similar results are found in other athletes that compete in sports that place a high demand on the shoulder like baseball, tennis or volleyball.  These athletes benefit from a greater degree of mobility of the shoulder and years of repetition in these sports enhances this mobility.  However, the pendulum can swing the other way as this mobility comes with the price of the increased risk of excessive motion, meaning instability.

Countless sports medicine journal articles have been devoted to examining the incidence of shoulder injuries in swimmers and in one such article, a review article examining the causes of shoulder pain in swimmers, researcher Dr. Casey O’Donnell states, “controversy surrounds whether swimmers acquire shoulder laxity as a result of repetitive motion, or whether swimmers with inherent shoulder laxity are more efficient in the water, which leads them to stay in the sport longer and compete at a higher level.”

But like many attributes, too much of a good thing can become a problem.  Too much shoulder motion can become instability after years of repetitive use.  For swimmers, excess mobility in the front of the shoulder can lead to pain and sometimes structural damage.  As swimming enhances the looseness of the front of the shoulder, additional stretching of the shoulder can contribute to the development of shoulder pain and laxity.  Because of this, care should be taken to minimize stretching the front of the shoulder as with a doorway or partner stretch.  When the front of the shoulder is inflamed or sore from the repeated stress of swimming, the shoulder can feel “tight”.  Responding to this feeling with more stretching can further irritate structures that are already “overstretched”.

While there is conflicting research on the topic, researchers at the University of California, Irvine found that the swimmers whose shoulders displayed a greater degree of laxity or looseness were more likely to experience shoulder pain.

Rather than more stretching, the emphasis should be placed on increasing the stability of the shoulder to balance the inherent mobility.  The rotator cuff muscles of the shoulder act to maintain the stability of the shoulder and strengthening of these important muscles should be a high priority.  In his article Dr. O’Donnell recommends that all young swimmers be instructed in a shoulder-strengthening program, specifically one focusing on the shoulder blade and rotator cuff muscles.

High volume of any sport or activity, even a non-impact activity like swimming, can lead to an overuse injury.  It is important to follow the same principles that guide runners, cyclists and dancers in the prevention of swimming injury.

Key Points

  • Swimming naturally develops the mobility of the shoulder.  Be careful with “extra” stretching of the front of the shoulder as this may contribute to the development of shoulder pain
  • Strengthen the stabilizer muscles of the shoulder; the rotator cuff and the scapular muscles
  • A frequent cause of shoulder “tightness” is inflammation of the front of the shoulder from too much stretching.  Avoid further stretching.
  • Include cross training and rest days into swimming program
  • Avoid large abrupt increases in swimming volume

The Pursuit of Optimal Performance

In our pursuit of optimal performance, every facet of physiology, nutrition and equipment has been scientifically evaluated and updated.  We have satellites tracking our speed, heart rate monitors to record intensity and a shoe industry that is constantly in search of innovation.  How did Roger Bannister ever break the 4-minute mile without Nikes and a GPS watch?

But for every scientific study that sends sports performance into new areas, there is one that extolls the value of simplicity.  One such area is sports nutrition.  The sports drink industry has bombarded the Internet and television with drinks designed to make athletes play longer and recover faster.  But do we need Ragin’ Melon flavored drinks to recover?

It is well accepted that exercise-induced dehydration will negatively affect later performance and replacement of lost fluids needs to occur after exercise.  Additionally well known is the need to replenish stored muscle energy, known to the scientist types as muscle glycogen, soon after exercise less subsequent exercise capacity be diminished.  Drinks that contain sodium and simple sugars have been shown to rehydrate faster than simple water.

While muscle energy/stored sugar can be replaced by solid food, rehydration can only be achieved with fluids; thus the recovery sports drink was born of the need to achieve both ends in one tidy package.

But rest assured, no stone has been left unturned by the sports drink industry.  Scientific research on the optimal composition, concentration and amount of fluid needed to optimize performance and recovery is constantly being transformed into the drinks seen on convenience store shelves.

However some of this recent research suggests that the items on your refrigerator shelves may work just as well as the drinks hyped up on television.

In one such study, cyclists were asked to cycle to exhaustion after previously performing an earlier vigorous ride with only a 4-hour rest period between the bouts of exercise.  The cyclists were either given chocolate milk, an energy replacement sports drink or a fluid replacement sports drink between the two rides.  Surprisingly, the cyclists that were given the chocolate milk were able to ride 50% longer than those given the energy replacement sports drink.  So much for Gatorade.

But what about team sports?  After all Gatorade was originally designed for University of Florida football players and if you turn on ESPN, chances are you’ll see a commercial showing basketball, football or soccer athletes guzzling Gatorade to help them recover.  Well, don’t forget non-fluorescently-colored boring old milk.  Turns out drinking milk after a hard practice helps those team sport athletes recover faster for the next practice.  The milk-fortified athletes ran faster than a group of those that just drank water.

Additional studies have validated milk as an effective post-workout drink.  Milk was more effective than a traditional sports drink in rehydrating after activity.  Researchers hypothesized that protein contained within milk not only had a greater effect on fluid balance but it reduced muscle damage after strenuous exercise.  Maybe that was the secret to Roger Bannister’s mile.

Add that to the fact that the high caloric value of sugar-filled sports drinks have been linked to the rise of obesity in children and adults and you may have another reason to stick with a more “natural” sports drink.  In fact, sports nutrition research suggests that you only need an energy (sugar) replacement drink like Gatorade after an hour of continuous exercise activity.  That’s the point that your body’s own stores of carbohydrates become depleted and need to be supplemented lest a decrease in performance or “bonk” occur.

Additionally, fructose, the type of sugar contained in sodas and fruit juices, is absorbed more slowly through the digestive system and delays rehydration.   This and the higher concentration of sugars typically found in fruit juices and sodas make them unsuited for optimal rehydration and recovery.

So while sports drinks have been scientifically formulated to rehydrate and replenish, they may not be superior to good old-fashioned milk.  So after your next strenuous workout you can reach for the chocolate milk and tell yourself it’s for optimal recovery.  Got Milk?

Injuries in Youth Sports

For parents and sports medicine professionals, youth sports present a complex riddle.  On one hand, participation in youth sports counteracts the worldwide rise in childhood obesity while on the other; youth sports injuries can cause both short and long term health problems.  How much is too much?

Participation in youth sports continues to become increasingly popular and it is estimated that 30-45 million 6-18 year olds engage in a form of athletics.  But along with this rise in participation has come an increase in the number of sports related injuries in young athletes with 30-40% of adolescents seeking medical attention every year for such problems.  Many of those children that are participating in youth sports are doing so in a year-round format, often playing on multiple teams during the same time period.  Because of that, overuse is a significant factor in the development of injury and some estimate that it attributes to 50% of injuries in young athletes.

How do we prevent injuries in youth sports?  It may start with not treating young athletes like adult athletes.  A combination of growing bones and underdeveloped muscle can leave youth athletes more vulnerable to injury.  For instance, while older pitchers can throw 90-100 pitches several times a season, research indicates that the risk of arm injury is directly correlated with number of pitches and young pitchers shouldn’t pitch with arm fatigue.  Similarly, addressing strength and coordination deficiencies in young female soccer players is most effective in early adolescence.

Furthermore, those young athletes that participate in a variety of sports have lower rates of injury and are more likely to stay active later in life than those that specialize in one sport before puberty.  Many “one-sport” athletes become “no-sport” athletes when they reach early adolescence because of burnout and injury.   Additionally, sport specific injury prevention programs have been shown to be effective in preventing injury.

To prevent overuse injuries, the American Academy of Pediatrics recommends that young athletes have 1-2 days per week without structured practices, games or scrimmages to allow physical and psychological recovery.  The organization also encourages 2-3 months away from a specific sport every year.

As only 1 in 200 high school athletes make it to the professional sports level, participation in youth sports with professional sports the primary goal is unrealistic.  As stated by the American Academy of Pediatric statement on youth sports, “The ultimate goal of youth participation in sports should be to promote lifelong physical activity, recreation, and skills of healthy competition that can be used in all facets of future endeavors.”

While the prevention of sports medicine injuries is a topic of continuing importance to medical professionals the risks of sports participation and physical activity are far outweighed by its benefits.  Youth sports are associated with lower rates of cardiovascular disease, diabetes and hypertension, among others.  Those that engage in sports early in life are more likely to remain active in later decades.  In fact, underuse as been associated with an equal amount of musculoskeletal pain as overuse.

For parents, the risks of under activity and childhood obesity must be weighed carefully against the tendency towards the over participation that is an ever to common result of youth sports involvement.

Achilles Tendon Injuries

Not to pick on the “weekend warriors” but those that continue to play soccer, basketball and tennis into the 30’s, 40’s and beyond are unfortunately at increased risk for injury.  One of the most dreaded weekend warrior injuries?  Achilles Tendon rupture.   The Achilles tendon is the most commonly ruptured tendon in the body, often requiring surgery and 6-12 months of rehabilitation.

Achilles tendon rupture has increased in frequency since the 1980’s due to increased participation in sporting activities, especially sports like tennis, soccer and basketball.  Men over the age of 30 with sedentary occupations (a scientific way of saying weekend warrior) are at greatest risk for Achilles tendon injury. Often those that experience the injury first suffer from chronic tendon problems prior to the injury.

However, regardless of gender, athletic activity is a risk factor for Achilles tendon injury as most of these injuries can occur to men or women during sports that require sudden accelerations and jumping.

While there is still debate within the medical community about the cause of Achilles tendon ruptures, researchers agree that decreased blood flow in a critical area of the tendon can lead to degeneration and eventual vulnerability of the tendon.  Once the tendon is weakened, an overwhelming load from a jump or quick start can result in a tear.  Think a tennis player trying to get an opponent’s drop shot or jumping to get a basketball rebound.

What causes this increased stress to the Achilles tendon?  One theory suggests that the calf muscles of those that tear their Achilles tendon have lost the coordination and strength that stems from a lack of use and reduced blood flow, possibly reflecting lost conditioning.

As a major contributing factor to Achilles injury is sedentary behavior, maintenance of exercise may deter a future Achilles problem.  Regular exercise can prevent the structural changes that can lead to Achilles rupture.  What’s more, strengthening may be more important than stretching as a study of Army recruits suggested that diminished calf strength and increased calf/Achilles flexibility were predisposing factors for Achilles tendon problems.

Additionally, Stanford researchers found that neither a standard program of warming-up nor stretching had any effect on the mechanical properties of the Achilles tendon, indicating that a physically active lifestyle is more the foundation of injury prevention rather than the minutes leading up to activity.  Researchers have also hypothesized that the inhibitory effect of pre-exercise stretching on muscular strength may also contribute to increased risk of injury.

What does all this mean?  It means that before starting that softball league or master’s tennis program, start hitting the gym for cardiovascular exercise and calf strengthening.  If you haven’t done any exercise for an extended period of time, start your new activity slowly.  The calf workout should include a focus on the eccentric or lowering portion of the exercise.

Do all this and you can become a “weekly warrior” not just a weekend one.

Back Pain

If you’re sitting down and reading this, your lower back might be hurting.  Want to fix the problem?  Stand up and keep reading.

First the bad news, if you haven’t experienced back pain, chances are you will.  Back pain is very prevalent and studies show that 65% of the population will experience back pain at some point in their lifetime.

Next the good news, back pain is more prevalent among those that don’t exercise.

While back pain can put a halt to exercise, it is often normal everyday activities that lead to the onset or worsening of back pain.  Sitting at work, in the car or on an airplane is frequently a source of aggravation that can affect later exercise.  Sitting, and all activities that round the back, puts pressure on the lower back disks and can lead to back pain and potential bulging or herniation of the disk.  Research shows that one third of those that sit for work will experience back pain.

Recent research in the Journal of Sports and Orthopedic Physical Therapy reported the results of a posture education and exercise program in a group of office workers.  The research study implemented a posture education and exercise program among office workers that dramatically reduced the incidence of lower back pain.  Not surprisingly, the results of the study point to the importance of posture and exercise for good back health.

Good posture habits should include frequent, short duration sitting breaks and avoiding the slumped posture by sitting “tall”.

If left untreated, back pain can become chronic and will often force a stop to exercise and activity.  While some activities can be linked to back pain, stopping exercise won’t necessarily cure the problem.

But all exercise is not created equal.  Common advice to those that experience back pain usually includes stretching the hamstrings and hitting the gym for some crunches.  The problem with this advice?  There isn’t any medical research that has been able to find a link between tight hamstrings and low back pain.  What’s more, stretching the hamstrings can also pull on nerves in the leg that are already aggravated, and make “sciatica” symptoms worse.

How about those ab exercises?  Well, while crunches can be an important piece of a core strengthening program, the abs are only a part of the core and other important muscles shouldn’t be excluded.  In fact, one research study that focused on back pain in a group of triathletes found that those that performed more ab work actually were more likely to experience back pain.  The researchers concluded that the athletes spent too much time on ab strengthening and not enough time strengthening other important core muscles such as the lower back, obliques, hip muscles and legs.

Back pain can become chronic and can prevent many from enjoying activities that they enjoy.  However, a small investment in posture and exercise can prevent back pain from becoming a problem.

Got Milk?

The milk industry has become well known for its “Got Milk?” advertisements that feature famous athletes with a characteristic “milk mustache.”  The calcium and Vitamin D found in milk is thought to help strengthen the bones of those that exercise (also the bones of those that don’t).  However, recent research suggests that the bones of all athletes are not created equal.

If you’re looking for reasons to start a regular exercise program, here’s another.  Like other tissues in the body, bones need a little stress to help maintain their strength.  With too little stimulation bones can begin to become thin and fragile.  Exercise, and in particular weight bearing exercise, has long been thought to improve bone density and most physicians recommend this type of exercise to those at risk for lowered bone density.  Women are at increased risk of low bone density, known as osteopenia or osteoporosis, later in life.  But consider this; not all weight bearing exercise has the same effect on bone density.

For instance, the research shows that swimmer Michael Phelps needs more than a glass of milk to make his bones strong.  Swimmers and cyclists, whose sports do not include weight bearing or impact, don’t stimulate their bones to stay strong.  Interestingly, mountain biking has been shown to be more beneficial for bone density than road cycling because of the repetitive jarring and vibration of the sport.

However, what may be surprising to many is that even the most jarring endurance activity of all, running, may not stimulate bone density as much as ball sports like basketball or soccer.  Researchers hypothesize that the repetitive moderate intensity impact of endurance running does not stimulate bone formation as much as the higher intensity, varied angle impact of ball sports.  The take home point is not starting your grandparents on a soccer program but rather that varying the type and intensity of impact exercise is a key facet of strengthening bones.

As the milk ads suggest, nutrition does play a role in bone density.  Age and gender appropriate levels of calcium and Vitamin D are important factors in keeping bones strong.  Nutritional researchers also point to the calcium lost through sweat as a significant factor for all that enjoy exercise.  Any significant amount of calcium lost through sweating is replaced by calcium from bones.  Nutritionists suggest that fortifying with a 1000-mg calcium supplement prior to exercise may prevent the body from leeching calcium from bones during sweaty exercise, especially for those at increased risk of low bone density.  Additionally, as skinny and slender athletes are at risk for low bone density and it’s associated risk of stress fractures and osteoporosis, eating a sufficient amount of calories is important for good bone health.

Orthopedically, this means that runners, swimmers and cyclists should consider mixing in a little soccer, basketball or aerobic class at the gym.  Changing it up might keep bones strong and fracture resistant now and in the future.