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.

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.