shin splints

The technical name in the sports medicine world is medial tibial stress syndrome. At the last talk I gave at Dick Ponds to a great group of runners, I had 2-3 in the crowd with nagging pain to the inside of the shin just above the inner ankle bone. At this point everyone had the pain early on in the run and it would easily go away by the next day. I didn't have the opportunity to check foot shape or Q-angle or shoe wear but I'd put my money on muscle bone irritation as the issue. I heard a fast solution from one of the runners as increasing the angle of the treadmill 1-2 degrees. I have to investigate that but sounds logical. Only problem would be the impact on the knees with the increased angle. My usual go to pathology with shin splints is to check the posterior tibial tendon.



Usually if the arch of the foot shows some collapse, there would be a tugging to the muscle tendon that comes down from the leg and inserts into the "fallen arch". One would think one inch shouldn't matter but after 30 minutes of pavement running, the one inch extra stretch will soon tear somewhere from the insertion of the tendon on the arch or the origin of the whole muscle group to the inside of the shin. Throwing an arch support into the shoe is easy, just have to make sure there's enough room in the shoe and that other parts of the foot won't be too compressed in an already "glove fitting" shoe. My friend Bob Weil, DPM, is great at constructing orthotics for athletes. http://sportsdoctorradio.com/index.html
In fact, in many cases, Bob has created orthotics and changed not only the angle of the foot arch but also the knee thigh and hip angles (also know as the Q-angle) to significantly improve friction issues at the knee or hip. We probably wouldn't hear much of these injuries a few decades ago in the 30-40 year old age group but now with the advent of the running clubs, 5k's and multiple endurance sports....overuse injuries are more rampant in the Boomers and X-gens.

The suggestion for cheap cure is throw an arch in (if it works you may want to invest in the permanents made by a podiatrist). Kinesio taping is coming back but some therapist/trainers aren't great at taping, it's a form of long lasting tape application that uses tugging on the skin to remind an athlete to turn out the foot and create an arch. Of course training the muscle group to be more adept at the 30 minutes of stress or increasing the pliability with hydration, omega 3 fish oil or deep tissue massage may help. Maybe just buying one of the running shoes built for "pronators" will do the trick. Finally, I always warn women about the possibility of stress fractures that masquerade as on and off pain. Backing off on the exercise will give the fastest results but this is usually a bargaining chip I save until later for my new athletes.

wii-itis

Carol comes to the ER with arm pain and claims no injury. No trauma, no old history of pain like this. I go through the usual and seems like the typical arm pain but yet no cause. After no success with history, I do the usual and hit the physical exam and hopefully the reason can be deduced when I have the pathology narrowed down. Looks like the pain is in the typical spot for lateral elbow pain(tennis elbow). Ok, easy, even if I cant locate the cause I can treat the disease.

Well, that would be too easy! (This is one of the reasons I left conventional insurance based medicine.....no challenge- with time comes knowledge and with knowledge comes confidence. With enough confidence I gained independance, creativity and a following. This is why I amat this place now. Not to sound egotistical but I am grateful for all I have experienced and I feel my penance for all this "enlightenment" is to share the knowledge and continue healing. Any time in the last few years and I would have said I have a vendetta against the medical "insurance corporation" but I now see there is a role for this business. The US is too dependant on this way of healing that stopping it would be a catastrophy. But injecting it with more "universal insurance" patrons is fuel for more of the same fire. Most of the primary care docs I know cant afford their own staff let alone take on more low reimbursement government insurance. So since no offices take the "medical card" they end up in the ER for big expensive tests and bandaid treatments designed to care for symptoms temporarily until a "regular" doctor is seen to finish treatment.

At the Harvard Course I voiced my angst and one of the teachers said creativity is beautiful but not with anger. I am still in my healing phase. Perhaps a meeting with Deepak Chopra is called for at this point. Well, as stated, this is too easy. The challenge is to find the cause. Finding the cause and not just treating the symptoms is what my "Saguil Approach" is about. I asked Carol further and I went through the motions of how a person with lateral epicondylitis usually moves.....immediately Carol say Wee! I thought....she must be having a good time! But I realized she meant the wii game. Apparently she had just purchased the game for extra exercise for her husband. She agreed on the cause of her pain as being the follow through in a right to left golf swing and we talked about how to heal and prevent further damage (and hopefully improve her video golf game.

It is good to see young kids and "gamers" doing more "exercise". But just goes to show that too much of anything will cause an overuse injury. Perhaps the next thing Wii comes up with is the Wii integrative medicine clinic! Story ends with me attempting to put acupuncture needles into that sore spot.....never got a chance to do so but hopefully Carol is working tomorrow on my shift!

I've fallen and I can't get up!

Young guy comes to ER after playing a league soccer game. (Are these guys fanatics!.....it's 30 degrees outside!) Claims he had a head-on collision with another player and they hit knee to knee and heard a loud pop! Couldn't get up at that point and went home with help. Tried ice and advil but no help and swelled up and got worse. I see him sweaty, in a wheel chair and in pain.

The rest is easy. Essentially only four things occur that result in a knee swelling immediately after impact.

1-fracture
2-patella(knee cap) dislocation
3-meniscus(cartilage) tear
4-acl(ligament) tear

The mechanism of injury is the most important item in deciding what the problem is. I always let the resident doctors I teach know how important history taking is when deciding on a diagnosis. The physical exam the doc does backs up the working diagnosis from the history. The imaging test will back up the physical exam. I felt the heat from the knee on this soccer player, pushed a little here and there and then pulled the leg forward slightly and immediately found the problem. Every test in medicine has a fancy name to it. My name will be famous one day (The Saguil Approach) - yeah right! The anterior drawer if done properly will yield enough without going any further (other tests are a lachman and pivot shift for the acl). The best way to confirm the anterior cruciate ligament is torn is the MRI. I have had several patients seen in the past that had the perfect history, the perfect exam and I didn't have to go further and sent them straight away to the surgeon.

The anterior cruciate ligament is a primary "stabilizer" to the knee. People can live without it but the knee will move excessively and probably give out with activities of daily living. With enough episodes of giving out, other problems will eventually occur: arthritis, a meniscus tear, a fracture, a broken ankle or hip. There are other ligaments that are secondary stabilizers and one can get along without them. The big surgery to fix the acl in the 90's was to take part of the patellar tendon and use it inside the knee as a new acl, tougher than the old one! Now surgeons us cadaver, hamstring or patellar tendons.....depends on the surgeon.

Unfortunately, this young guy worked standing and walking. Also didn't have insurance. Just the xrays, crutches, knee immobilizer, meds and ER visit alone will cost him about a grand. The surgery will probably cost 7500 with the rehab. He doesn't have to get the surgery but the knee will probably give out everytime he turns. In the 80's, there were some researchers who claimed if you placed a "derotation" brace on, it will prevent the knee giving out. Naaa!

Unfortunatley, not easy to predict who will tear. Contact sports for sure, in this case, soccer is considered non contact. Happens alot with women due to a few anatomic issues. When I was team physician for Benedictine University, the womens basket ball team had about 3-4 "acls" in one season and we traced it back to the teaching techniques of the assistant coach. (Had to rule out surface, shoes, players and training) We changed techniques and next season, no problems.

I have heard some docs getting results from prolotherapy. This would be injecting stimulants to growth into the knee to speed up healing. I haven't seen enough research to say it works compared to surgery (probably not ever see a study due to funding) and havent talked to anyone that does alot of it so can't comment on success rate. Like anythin in integrative medicine, I push for alternative treatments to a certain degree, but if mechanics are altered or can be fixed with western medicine, go for it!

Stretching the Charles Atlas way!

Ok.....when most the 40+ers think yoga, there is a picture of and Hindu man with a turbin, a basket, a cobra and a flute. Only those who have experienced training in a martial art or tried a yoga "sampler" class will understand the power of meditative breathing and "chakra stretching". Many people I speak with about losing weight or lowering blood pressure using yoga alway come back and say, "I'm not flexible" or "I hate stretching". The stretching part is obviously only the tip of the iceburg when it comes to benefits of eastern medicine. Ayervedic medicine incorporates diet meditation, breathing and exercise/chakra stretching. Chinese medicine is less organized but also encompasses the same lifestyle of happiness, use of foods for healing, exercise/tai chi and spirituality. Most people don't get to the level of martial arts where touch is used to heal instead of harm/defend. (Mostly because today's dojo's are "blackbelt mills" but dont get me started!)

People who can afford personal trainers, usually have the benefit of the hired knowledge to get into the pre-exercise muscle-heating stage. Unfortunately, the average person will have to learn this from example and trust it is worth it to learn. Problem is that to initiate the flexibility routine is actually painful and frustrating. Probably takes about 2-3 months to become flexible, then if you are lucky one will feel the benefits return to the spirit as the chakras are stimulated. That is if you can afford learing from a certified teacher. The Saguil approach to accepting this as a key component in your fitness routine is that during the 20-30 minutes of breathing, imagery, stretching, the heart and brain are given more reward than the 30-60 minute endorphin release from weight training or cardio. No question the "bullet proof" effect of cardio on heart disease but I think of meditation, breathing and chakra positions as "bullet proofing" the mind and heart during the remaining 23 hours of a stressful day. I like what the folks in chicago have done with yoga.....http://www.yogachicago.com/ (check them out)

I have called several places and the head instuctors usually will allow one free visit to experience what they teach. Give it a try! It will make for an injury free workout and a more rewarding fitness experience. (...may even be able to throw away a blood pressure pill in the process)