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.

Why should you lift weights?

Why should you lift weights?  Sure, you’ll look better at your next pool party but does it really improve athletic performance or prevent injury?  Well, washboard abs and chiseled biceps non-withstanding, improving muscular strength and function can help in a variety of ways.

A great deal of research has validated the effect of improving strength on endurance exercise performance.  Improved strength made runners and cyclists faster at the end of a long race, improved efficiency and increased muscular power.  One such study in which cyclists were asked to pedal at maximum intensity for five minutes at the end of a three-hour ride improved their performance when they combined their traditional endurance program with strength training.  The improvements were significantly greater than those of a group that only followed an endurance program only.

Play golf?  Researchers in the Journal of Sports Science and Medicine concluded that, “Training leg-hip, trunk power and grip strength are especially relevant for golf performance improvement.”

But what does that mean for those that don’t regularly toe the line at the San Francisco Marathon or race Ironman Triathlons.  Well an unfortunate fact of aging is muscle atrophy and loss that begins in the 30’s and 40’s.  This loss in muscle, while sometimes offset by the purchase of a shiny sports car, can have far-reaching effects on the body, including but not limited to; decreased metabolism, weight gain, increased risk of injury and osteoarthritis.  If that’s not enough to send you racing to the gym, how about this fact; the age-related loss of muscle and strength can lead to a greatly increased risk of falls and fractures.  Additionally, a study in the journal Arthritis and Rheumatism linked decreased quad strength with an increased risk of osteoarthritis.

The importance of muscular strength and function for the prevention and treatment of orthopedic injuries is well established.  For virtually every orthopedic ailment, improved strength can lessen the chance of being sidelined with injury.  A 2011 article in Medicine and Science in Sports and Exercise found an association with lowered calf strength and the increased incidence of stress fractures in the lower leg.  Similar studies on swimmers have found that decreased shoulder strength increases the risk of swimming related injuries.  As mentioned in previous blog entries, quad and hip strength are important in preventing running related overuse injuries.

So if you’re looking for a reason to start using that dormant gym membership, whatever your motivation or activity level, strength training can improve health, reduce injury and enhance performance.

At Some Point We All Become Weekend Warriors

At some point we all become weekend warriors.  The weight of work schedules, commuting, carpools and travel become increasingly difficult to manage.  Exercise becomes relegated to early mornings or quick gym workouts that don’t have the regularity of those carefree and time-filled days of yesterday.

Other than making it harder to justify that extra piece of dessert, these infrequent workouts can make injuries more likely when we do find time to play softball, soccer or ski.  When muscles and joints, especially those accustomed to the more placid demands of the elliptical or recumbent bike, are subjected to the intensity and acceleration of more dynamic sports like soccer, muscle strains can occur.

Muscle injuries are a common injury even in those that play sports at the elite level and a frequent cause of missed competition.  A recent study of professional Australian footballers (the Aussie version of rugby) found hamstring injuries to be the most common injury, accounting for 12% of all injuries.  Unfortunately for weekend warriors, the studies’ researchers identified increasing age as a risk factor for injury.

Now don’t despair, several other, more correctable factors were associated with muscular injury risk; muscle strength and previous injury.  Surprisingly, a lack of hamstring muscle flexibility was only weakly associated with hamstring muscle injuries.  However, with injuries to the upper thigh or hip flexor muscles, muscle flexibility played a more important role.

But what constitutes a strain?  When does lasting soreness after a hard workout mean injury?  Terms like “muscle pull” or “tear” are used to describe muscular injuries but there is little consistency with how these injuries are classified.  Although it may be difficult to find common descriptive terms for muscular injury, there is consensus on how limiting these injuries can be to the professional and recreational athlete.

In general terms, muscular injuries can be lumped into three grades, depending on severity.  Grade I injuries refer to mild strains without any tearing or disruption of the muscle while Grade III injuries involve extensive muscle tearing.  Grade II or III injuries often require the use of crutches and months of recovery.  Regardless of grade or severity, the difficulties with muscle strains can be due to their recurrent nature.

In many cases, recurrence of a muscle strain can result from inadequate healing time after the initial injury.  While painful and debilitating in the first week after injury, the injured muscle can seemingly recover quickly.  However, despite the lack of pain or dysfunction even a mildly strained muscle can remain vulnerable for 6-8 weeks after the initial injury.  Hurrying back to soccer or softball too quickly can doom the weekend warrior to chronic problems.

So what can you do?  First exercise your patience; several extra weeks of healing can make a huge difference in keeping a muscle injury in the past.  Second, exercise your legs, but do so in a way that doesn’t overstress the affected muscle.  The stationary bike, yes I know it can be a little boring, is usually the best place to start cardiovascular exercise.  The bike can be spiced up with in and out of the seat interval training that will keep it interesting and maintain conditioning for the eventual return to sports or harder activity.  Additionally, as stressed by the above research, a strong muscle is more resistant to strain so initiating a strengthening program that gradually increases the strength of the injured muscle is an important factor in treating the problem.

Stretching can play a role in the rehab process but should not be included in the first two weeks of treatment for a strained muscle as it can pull on already stressed and healing muscle fibers.

And please, if you are going to embody the label weekend warrior, doing some consistent and vigorous preparatory exercise before trying to channel your inner Mia Hamm, Kobe Bryant or Shaun White, is also good idea.

The Forgotten Muscle

The Forgotten Muscle

If you pick-up any popular running or cycling magazine that includes exercise medicine you will surely see kneecap pain as a common topic.  Knee problems, particularly kneecap or patellofemoral pain, are the most common injuries among those that exercise.  But for all the experts and carefully designed research on the subject, the majority of articles miss the boat.

The current trend in physical therapy and sports medicine is to consider hip strengthening, specifically of the outside or lateral hip muscles, to be silver bullet of kneecap rehabilitation.  While many studies examining the hip strength of injured subjects have found consistent correlations between decreased hip strength and kneecap pain, they are limited in their analysis of the problem.  As the majority of these articles use subjects that already have developed kneecap pain, the researchers cannot accurately state that weak hips cause kneecap pain.

A review article in the British Journal of Sports Medicine recommends “more prospective research is needed to clarify whether less hip abduction strength and hip external rotation strength rather is a consequence of PFPS than a cause.”

In fact one of the few studies to examine the hip strength of runners before beginning a running program did not find any correlation between decreased hip strength and kneecap pain.

This current thinking has everyone spending time exercising the hip but neglecting the muscle with the most influence on the health of the kneecap, the quadriceps.  While the quad’s importance would seem difficult to overlook as it is attached to the kneecap and is a critical shock absorber for the entire leg, strengthening the muscle is often a secondary consideration.

While lateral hip strengthening is an important component of treating kneecap pain, clinical and research evidence points to the value of focusing on quad strengthening.  A review study in the Journal of Sports and Orthopedic Physical Therapy used gold-standard prospective studies to examine potential risk factors for patellofemoral pain.  What did the combined research determine was the singular factor that predicted future problems? Lack of quad strength.

Adding to the problem, reconditioning the quad can be difficult as a loss in muscle tone after disuse and pain can make strengthening the muscle possible only with skilled guidance.  Many common gym exercises that are used to strengthen the quad, like the knee extension machine, can further aggravate the problem.

So if you want to look good in tight jeans, follow the advice of many popular magazines and only focus on hip strengthening.  If you want to stop your kneecap from hurting AND look good in tight pants, strengthen your quads and your hips.

Platelet Rich Plasma Therapy

The Internet is a powerful tool and anyone with a connection and a device (i.e. everybody) can dial into an almost unlimited stream of information.  But with the flood of testimonials, Yelp pages and blogs it can be difficult to determine fact from fiction.  The continually evolving field of medicine can accentuate the difficulty as treatments, medicines and surgeries can change at a pace that even Wikipedia can’t keep up with.

One such topic in the field of sports medicine is the use of concentrated portions of the blood as agents to speed healing and tissue repair.  Kobe Bryant famously flew to Germany for treatment of his knee with one such product, Regenokine.

For most of us without a private jet and millions in disposable income, the more common treatment is known as PRP (Platelet Rich Plasma) and is increasingly used to speed up tendon and ligament healing after injury or surgery.  Platelets are an important part of the bodies healing response after injury and their concentrated growth factors are the theoretical reasons behind the use of PRP.

PRP utilizes a small portion of blood drawn from the patient which is then spun in a centrifuge to isolate the platelets and re-injected into the affected area.  While the science behind PRP therapy is widely accepted, its manner of use is not.  Confusion can result as the method of preparing and injecting the PRP-product can vary among physicians.  As a result of this, the type of administration and treatment protocol can affect the clinical outcome of the treatment.

While originally used for tendon injuries, PRP use has spread into surgical and non-surgical interventions.  PRP has been commonly used for chronic tendon injuries and has shown success in treating “tennis elbow “or lateral epicondylitis and patellar tendinopathy or “jumper’s knee”.  With these procedures, the PRP is injected directly into the tendon, frequently under the guidance of ultrasound.  Immobilization and rest of the treated area frequently follow the application of the PRP treatment.

According to a review article in the journal Physical Medicine and Rehabilitation, most patients experienced a reduction in pain when PRP was used to treat their lateral epicondylitis.  However, conflicting outcomes can be found as similar research found PRP no more useful in the treatment of tennis elbow than a saline injection.

Recently, PRP has been used during ACL reconstruction in an attempt to aid in the healing of the bony tunnels and speed the incorporation of the graft into the bone.  While it is similarly used in rotator cuff surgeries, early clinical studies do not show any added benefit when used for either rotator cuff or ACL surgery.

In a recent article in the American Journal of Sports Medicine, PRP showed positive effects in temporary alleviating the symptoms of osteoarthritis.  These improvements lasted for approximately 6 months after the injection of PRP.

Despite its widespread use, PRP shows mixed results and research suggests that its effects can vary depending on where and how it is utilized.  Generally, there isn’t a “silver bullet” treatment that can cure all orthopedic ills, PRP included.  When PRP is indicated, it should involve a comprehensive program that includes physical therapy, possible immobilization and progressive return to more strenuous activity.  Stay tuned (or logged on) to get the latest in PRP research.

The Stairmaster

Many view the Stairmaster in the same light as Wham, parachute pants and break-dancing, relics of the 80’s that are best left as memories.  While it is true that parachute pants shouldn’t be resurrected, the Stairmaster should still be considered an exercise that stands the test of time and technology.  The problem is, everyone in the gym wants something 21st century, with flashing numbers and heart-rate measurements, and the fancy and popular elliptical trainers fit the bill.

But is newer better?  One factor behind the popularity of elliptical trainers is their notoriously generous calorie count.  But hold on, a study in the Journal of the American Medical Association or JAMA, compared the calories burned during 3 different intensities on the treadmill, elliptical/cross-country ski machine and Stairmaster.  After an hour of exercise at the highest intensity, subjects used the most calories on the treadmill, about 850 calories per hour.  Second place?  The stair-climber was the runner-up with a total of 700 calories per hour.

Doubt it?  Use the sweat test-try 30-min on the Stairmaster versus 30-min on the elliptical.  I’ll bet you a Sheena Easton Greatest Hits CD that you’ll sweat a lot more on the Stairmaster.

Other interesting questions have been raised about the ellipticals’ effectiveness and safety.  One such research study found that while elliptical trainers are non-impact they could increase the stress to the kneecap when compared to treadmill walking.

Research has also validated the cross-training effectiveness of the Stairmaster as a study found that those who used a Stairmaster to prepare for a running test performed comparably to those that used a treadmill to train for the same test.

So if you’re looking for a way to a great, efficient workout or want to effectively cross-train during injury, the Stairmaster may be superior to all the other gym options.  So put your best mix tape in your Walkman and sweat away.

Barefoot Running

The fitness world is always eager to embrace the latest fitness trend.  Tae-Bo once swept the nation, Cross-Fit gyms are to numerous to count and many were seen tottering down the street in MBT African tribe inspired shoes that promised to eliminate sore knees and backs.  The only thing that surpassed the fervor over which these new trends were adopted was the speed at which they fell from favor.

After reading the popular book Born To Run, many rushed out to buy barefoot/minimalist shoe as the author offered compelling evidence that we were meant to run in a manner that has the front of the foot striking the ground first.

Research from Harvard biomechanist Dr. Daniel Lieberman seems to support the evolutionary nature of this running style as he observed that when people run without any shoes they tend to land on the front or middle part of the foot.  Why?  Because hitting the heel first is like a mini-collision with each step as the heel acts like a brake each time the foot hits the ground.  He found that the force was 2-2.5 times bodyweight when a runner struck the ground with the heel first but forefoot strikers only experience one-third that force when running.

Supporters of barefoot running claim that shoe companies have attempted to cushion and arch-support the shoe to disperse some of this force but by doing so, changed runners to heel-strikers.  Barefoot proponents say that cushioned heel strike running style enabled by the modern running shoe leads to overuse injuries of the foot, ankle and knee after miles and miles of running.  While the very purpose of the highly cushioned, elevated heel running shoe was to lessen the chance of injury, it would seem that it created a running style that increased the force and stress experienced by the lower leg when running.

While science behind barefoot/minimalist running is generally well accepted, its significance for runners is not.  The first issue is that barefoot shoes don’t automatically confer a change in running mechanics as those heel striking runners that switch to a barefoot shoe generally continue to heel strike, despite the change of shoe.  The assumed advantage of barefoot running is only for those that change how they land with each step.

The bigger issue is that despite clear evidence that landing on the front or middle of the foot when running lessens the impact, a corresponding decrease in injury does not seem to occur.  Additionally, changing how one runs may not offer any performance advantage.  Little yet is known about the long-term effects of switching to a barefoot running style.  Does it reduce injury?  Should the injury prone switch or those that run injury-free?  All of these questions need to be answered before the sports medicine community embraces barefoot running.

Spring Means Baseball

News that the groundhog didn’t see his shadow isn’t the only indication that spring is on the way.  Spring means baseball, longer days and hot dogs and sunflower seeds at the baseball game.  With pitchers and catchers reporting to spring training this week, fans are filled with a fresh sense of optimism that their favorite team will be a contender.  Sports news begins to focus on players who have moved to new teams and those that are returning from injury.

In the baseball world, no injury captures more attention than “Tommy John” surgery.  Named for the first player, Los Angeles Dodger pitcher Tommy John, that underwent successful surgery for repair of a torn elbow ligament in 1973, the injury and surgery result in a year of lost play.  Thankfully, for those that experience the injury, usually pitchers, most are able to return to a prior level of performance.

However, many have the misconception that the surgery will actually enhance performance and physicians have reported many instances of young athletes asking for the surgery with any sign of elbow soreness.  Dr. Thomas Ahmad, orthopedic surgeon for the New York Yankees, recently published a study in The Physician and Sports Medicine that showed 50% of the student athletes surveyed believed that Tommy John surgery should be performed in the absence of injury.

This research, along with the concerning rise of overuse arm injuries in high school aged athletes, suggests the trend that coaches and athletes have become more reckless with health, falsely believing that surgery can correct everything.  In a recent study, research by Dr. James Andrews reported that 5% of all youth baseball players will develop elbow or shoulder problems that will require surgery or force them to give up baseball, most of which are linked with the amount of pitching.

If the UCL elbow ligament ruptures and Tommy John elbow surgery is needed, an extensive rehabilitation program is needed to regain the range of motion and strength required for a return to throwing.  After 5-6 months of physical therapy, a progressive throwing program can be started.

Many of these injuries result from a combination of poor mechanics and the year-round format of many youth sports.  Physicians recommend that youth pitchers take at least 2-3 months a year off of throwing so that their tissue can recover and avoid rupture.  It is important that players, parents and coaches understand that a young athlete’s muscles and bones are growing and need to be protected from overuse.  Given the inherent risks and lack of guaranteed success, surgery should never be considered a performance enhancer but rather a means to hopefully restore the lost function of a joint.

Stretching – Timing is Everything

Stretching has long been known to improve muscular flexibility and joint range of motion and is considered an integral part of any fitness routine. Gym teachers and coaches have taught us that stretching before exercise keeps us injury-free and performing at our best.  But does it?

The usefulness of stretching immediately before exercise has become a much-debated topic.  A great deal of research seems to suggest that static stretching, or the type of stretching that most of us are accustomed in which a stretch is held for a sustained time, has been linked to decreases in muscular performance when used immediately before exercise.  These decreases in performance have been observed in explosive type activities such as jumping and sprinting.  After reviewing several hundred articles on the subject, a recent article in the Scandinavian Journal of Medicine and Science in Sport concluded that pre-exercise stretching induces a short-term negative effect on muscular strength and explosive power.  These reductions were independent of age, gender and athletic ability.

But wait, endurance athletes might not be safe from a similar effect.  Several studies have shown that stretching acutely affects endurance economy, meaning that it takes more muscular energy to run or cycle after pre-exercise stretching.  While it seems like the diminished economy is short-lived, those that stretched before exercise didn’t run or cycle as far.

Researchers theorize that the performance losses in both strength and endurance activity come from changes in the stretched muscle that leave it temporarily less able to produce force.  These changes are small but significant and seem to last for a short period after stretching.  Sports medicine professionals have pointed out that for those athletes whose activities require the extremes of joint range of motion, such as ballet dancers and figure skaters, the improvement in range of motion may outweigh the negative effect of pre-exercise stretching.

What’s more, stretching before exercise doesn’t seem to have any effect on the risk of injury.  Research on both static and general stretching indicate no clear benefit on the overall risk of injury.  There does seem to be a slightly lowered risk of muscular injury with static stretching.  Additionally, stretching has been shown to be a beneficial for those recovering from injury.

However with stretching, as with many things, timing is everything.  While experts have concluded that stretching immediately before exercise results in diminished performance, a regular stretching program, performed after exercise, does not decrease muscular performance and can even be beneficial to performance.  Several studies have found improvements in speed and jump height with regular stretching.  Additionally, if there were a protective effect of stretching, it would seem to result from a regular stretching program.

So what should you do before your next run, race or basketball game?  Although static stretching is the wrong answer, a sport-specific warm-up is not.  A general warm-up such as light jogging followed by a sport specific one can improve performance in explosive and endurance sports.  Not surprisingly, well trained cyclists performed significantly better after a warm-up, regardless of intensity.

So unless you are a ballet dancer or gymnast, save the stretching for after the workout and spend your time warming-up instead.