Shoulder Pain

I turned 40 in 2002 and as I approached that age, I was involved with a lot of x-games sports.  I remember rock climbing and attempting a "dyno".  (this is when you grab onto the ledges, pump up and down building up momentum and launch up to grab a hand hold somewhere above you .....Tom Cruise in MI 1) and missed.  It resulted in a year of not being able to bench press, lift overhead, and catching of my shoulder with any movement.  Some of my old patients may remember when I was working with a huge ice pack on my shoulder for 3 weeks.  I had seen my physical therapist who specialized in throwers, I took some of the best prescription medicines available, even got ready for arthroscopic surgery after the 6th month of not being able to exercise.

At that point, I had stumbled on alternative healing.  While an employee of CDH, one of the stipulations in my contract was to have my CMEpaid for, I chose a seminar in California with some guy that was teaching acupuncture to pain medicine doctors.  I planned on signing my name on the roster, blowing off the lecture and hanging out at the beach.  The keynote was made by Dr Joesph Helms and I remember sitting in the front row in a room of 800 doctors and with my long hair (midlife crisis) challenging him with questions on acupuncture in sports medicine, acupuncture in pediatrics, acupuncture for medical diseases.  But this guy nailed all my questions with very intelligent answers!  Then when he asked for a volunteer, I gave him my body (very skeptical and anxious to get to the beach).  Remember my shoulder was still painful and limited with range of motion from the rock climbing injury earlier in the year.  He place 3 needles into my shoulder and within 10 minutes, I had pain free, range of motion just like my pre-injury state!   I was sold on this weird 2500 year old concept of healing.  Thus began my journey into alternative and complementary medicine.
Note that I still had to do my rotator cuff exercises, my scapular stability exercises, take glucosamine sulfate, and have acupuncture 2-3 times a week for a few months.....but I avoided surgery and now have regained full range, better strength than before and can do hand stands in yoga at 51 years of age.  (the acupuncture isnt just a passive treatment, it helps the body heal so anyone with injury or disease still has to put in the sweat equity and maintain the building blocks to health and healing (see my Anti-inflammatory Lifestyle video here).

Tight Hips

Had a new guy start in my Meditative Yoga class at Northwest Community Hospital Wellness Center.  Spotted the usual difficulty with keeping still during opening breath work in Sukasana (sitting crosslegged).  Figured either anxiety sufferer or leg problems.  He came up after and turned out to have a hip problem.  Guys usually have big muscles and poor flexibility.  The short-cut in figuring which machines to use or barbell movements to rely on is do what is most popular in the mags or just go down the machine line and hit one body part at a time.  Problem with applying general body region movements or machines is you have to be in posession of an "average" body.  In my sports medicine clinic, even between twins I find differences in knee alignment, foot arches, posture, muscular thickness, pain tolerance.  So applying general guidlines to and individual person is a formula for failure due to non-sustainability. 

What also is a "curve ball" in developing a personal exercise/movement routine=what are the end goals.  Cross training for running, shoulder development for looks, bounding height for dunking, flexibility for mixed martial arts, power for contact sports.....this is where it is so important to get a "second opinion" on applying an exerciser routine to your life.  I don't mean with a sportsmedicine doc, I highly value to ingenuity of exercise physiologists in figuring risks, strengths to embrace, weaknesses to address and lifestyles that would limit a long term sustainable life change.  So this is where my tight hip/50+ year old yoga student has entered into the "melee" of personal fitness programs.  For the short 8 weeks of having him come for guidance, I can at least help him in planning a continued exercise/overload program.  If we can use 3 easy poses of yoga as a staple or preexercise warm up, over time he should be able to gain progressive lengthening to a very contracted hip capsule.  Keep up with the basics no matter how deep he gets into other sports/activities and one day he'll have the flexibility of a highschool gymnast. 

Problem with hips is most americans view the groin and hips as very private.  The figurative concept of hiding from sight always translates to physiologic function.  Although a painful image, think of a sexually abused kid dreading the gyne office PAP smear when she gets into her 30's.  The psychology of injury always limits the form and function.  One of the reasons I save hip poses for the end of class is for the first 45 minutes, I not only get students to warm up body temperature but they also have worked on breath and relaxation so any psychological worries are not as distracting compared to before class.  If all distractions (I mean psychological ones like "my hip is about to break" or "feels like the muscle is going to tear" or "shoulder is about to come out!") are calmly removed from the forefront of one's attention, it will usually be able to apply exercise/overload.  Getting to the point where the hip is tight in the movement but not terribly painful....then holding at that point, concentrating on breath, and when guided-slowing coming out of the pose with control.  When I was captain for my school Track and Field team, I would lead warm up and remember bouncing the joint in the 1980's to provide warm up, flexibility, and stretching-usually on cold ground!.  (How wrong I was!!!)  The slow entrance into range of motion, gradual addition of torque and length, and relaxed breath will usually convince the muscle group to release it's contracted state after minutes.  Some will note after a long hold the sudden realization that the knee is now touching the floor in pigeon pose or the forehead is on the knees in forward fold.  (Others it takes a few months)

Here is a video link to a few poses that I showed my student and helped him to adapt (via use of yoga blocks and blankets) for daily repetition/ritual. 

Of note is it took me 2 years to attain pigeon pose equal on both right and left.  I suffered a hamstring tear going around the back stretch 110yards in a 440yard medley for state championship and coach said he heard a pop from across the field.  Cost the team 1st place and always held that in the back of my mind (and the back of my hip)...and that was 1979!

Mommy Wrist

Something about the having a baby is just beautiful, ask any mom.  Then there's the fragmented sleep, weight gain, transition back to running a house and working......and wrist problems.  Carpal Tunnel has been so published/talked about in the last 20 years that anyone will be able to figure out if their symptoms are similar and find conservative treatment to start online. 

I had a patient come in referred by ob/gyn.  Second time around mom with wrist pain that was "different".  Started about 6th week after leaving the birthing center and has been persistent since.  Mom is now 3 months out and suffering.   Tried to use the brace from walgreens for carpal tunnel with no help.  Pain grabs her with certain movements and now is interfering with sleep.  No history of this before and no trauma.  Still breast feeding but planning to wean off and return to work in about a month.  (Incentive to get the wrist pain resolved since she uses a computer 8 hours a day)

There are a few things I watch out for in anyone complaining about joint pain.  First is always broken bone or tumor.  Luckily with the wrist, small joint, easy to evaluate.  Then I think in mechanical terms and locate the area of pain/dysfunction.  Finally look above, below and referred.  In rare cases the pain will come from soft tissue like infection, other tissue, blood vessel or metabolic problems.  If I can't find a good solution or patient has tried everything, time to add traditional chinese medicine  and break out the needles to "move stuck energy" until conventional modalities start to work. 

If the pain is evaluated early, usually history gives the diagnosis (physical exam and testing backs up the dx).  If the pain has been "lived with" for a long time, the presentation can be different as the average person will compensate and may not remember the new symptoms vs the old symptoms.  Detective work ensues (experience and listening) and chipping away at confusing red herrings starts until the true problem reveals itself.

In this case, I ruled out scaphoid fracture (very important bone in the wrist that if ignored, leads to chronic disability) and went straight for the gusto-finkelsteins test.  BINGO! reproduced pain exactly.  This is notorius for moms as they reach to pick up 3-4month old (baby has good head stability by then) and lift up play face to face.  Gave a specific splint for thumb immobilization, advil (only antiinflammatory ok with breast feeding moms).  Also suggested facilitating healing with diet control (no dairy or wheat), turmeric and magnesium (ok with baby) topical treatment (helicrysium, tea tree, traumeel, ice massage) and acupuncture as back up if not better in 3 weeks.   If all else fails, steroid injection into the sheath of the tendon will help, and shouldnt effect breast mild production.  By then occupational/physical therapy will problably be necessary. 

ACL's

So RG3 is scheduled to get into sprint and cut mode by fall 2013.  When I did my sports medicine fellowship with DePaul in '95 I remember Preston Wolin showing some of his slides (no PowerPoint back then) on acl basketball players jamming from the foul line within 4 months post surgery!  I also remember the gasps coming from the other docs at the conference.  It seems like we push the envelope on getting people back into the damaging activity they were initially injured in.  Why is this?  To get more viewers? To be seen in your 4th year of athletic scholarship during March Madness?  To win for the team?  Nothing else to do?

Problem is we treat the ligament and do nothing for the person.  Just cause you have a full boat scholarship doesnt mean you eat all organic, get quiet time to maximize healing, get good rest to recharge the brain, or dive into community love.  Wouldn't you say the best chances for healing in cancer (the Emperor of all Maladies) is with medicine/surgery and all the above?  So what is the difference with surgery for an acl and healing.  In the last 20 years the materials used for acl repair have gone from mesh to cadaver to same side patellar tendon/opposite side patellar tendon to triple twisted hamstring.   Regardless of which one, the longevity is overall about the same and results are more dependant on the health of the surgical candidate.  (Put a million dollar graft in an obese, diabetic smoker and results will be poor/put a cheap piece of fiber in a fine tuned 20 year old and s/he will be performing 80% on a single leg hop within 3 months.) 

So for the sake of this blog; things to improve outcome. 

-You must know the ins and outs of your surgical issue and all the newest controversy.  And don't just rely on Joe Mercola's website for information.....research acsm, google scholar, pubmed, nih to name a few places. 
-Never stay with a rude surgeon no matter how good his reputation is.  Some surgeons have "peculiar personalities" like to debate/name things after themselves/be captain of the ship....just kidding-many good friends are surgeons. (I also know of some big assholes that shouldn't be practicing medicine) First and foremost-a patient has to be his/her own advocate so know your rights and trust your gut. 
-Most of the major sports teams have medical groups that pay to be the team docs.  Yes they contribute indirectly to the sports franchise to be the guy.  Not in kickbacks or financial incentive.....more like locker time, trainer training, "free coverage".  So it depends on how good your results are, who you know on the board, and how much you can "give" of your time/staff.   So if in a strange city (ie Colorado with an acl skiing injury) ask for the "pod" that works for a major sports team) Pod = orthopod for short but its like calling a police officer a cop.
-Always go to primary care to make sure you are maximized to heal.  This doesn't mean get a family practice guy to sign off that you are ok for anesthesia.  (I have always though this presurgery physical is a waste of time.....only thing I use it for it when I remind my surgical candidates that they have to lose weight, see a therapist, lower cholesterol or work to get off their medicines.)  This means having a professional nit pick your sleep, nutrition, look for vitamin deficiency, get you into "prehabilitation" so you don't go into surgery with poor exercise tolerance, endurance, stamina, strength.  Post surgery outcome can be improved if you fix the thyroid, improve the IBS, work on the food allergies or beef up the depression.  You do want to start healing asap right?-why not prior to surgery.  There are prolotherapy techniques that are only done by a few docs (I've been using Ross Hauser in Oak Park since the 90's) and now PRP, to mention one type, is catching on with orthopedic surgeons to facilitate healing.  (essentially using natural healing products to speed the body to rebuild-that Hippocrates guy knew what he was talking about!!!)  For the low grade acl tears/strains that the surgeon wont cut on, definitely worth prolotherapy but little expensive and not covered by insurance.  Better than just watching it and using the ol' Donjoy  "derotation" brace.  I had a football coach for Holy____ High School every game lay down on the field and say he needs a second to get his knee back into place.  He had an acl tear that was unstable, was told to just watch it by his orthopod, but wasnt told every time it gave out, there was an 80% chance of tearing a meniscus/cartilage.  At this point he probalby has already gone through total knee replacement....nice advice from his doc.  (I told you there are some docs that shouldn't be practicing medicine.  A license to practice medicine and no concept of healing is like allowing the mentally unstable gun permits.)
-Get a good Chinese medicine trained acupuncturist to help with the healing process.  As long as you don't use the chinese oral herbs, no need to ask the surgeon.  If needles aren't placed within 6inches of the surgical site....cannot blame the acupuncturist for anything.   And the surgeon wont know anything about acupuncture and will just say don't do it.  I was at a ACSM conference with the biggest pods in the country and a question came up, if NASCAR drivers with back pain would benefit from acupuncture (heat usually comes right up the seat in the car) and a pod immediately said there was one study that said acupuncture doesnt work.  (Kiss my sit bones dude, not reading the right papers!!!)  Of course all the young up and coming resident/docs were writing in their notepads..."acupuncture doesnt work".  Of course if needling speeds up recovery, it is the surgeons skills that did it!
-Pain control is to be coordinated with the primary care guy (if s/he is good with botanicals) or the naturopath.  There are great botanicals that help with pain, decrease the dose of prescription narcotics, and don't interfere with healing.  In fact there are great homeopathic meds that speed up healing not too mention aromatherapy (I love the essential oil-helicrysium....helped me get through 2 marathons with no pre marathon training!)
-Nutrition and food technology is growing by the minute so the old concepts of eating what ever tastes good can slow down and hurt your chances for fast healing.   Enlist the help of a registered dietitian.  What you are eating, when you are eating it, what supplements you take could be archaic.  Why not give what every cell in your body needs to work DNA.....and no, Hooters Organic Chicken is not healing (maybe to the eye). 
-I am a yoga instructor as well as a sports medicine doc so I always embrace the mind body medicine power of facilitating healing.  Even if you dont meditate 30 minutes twice a day, visualization helps prior to and after surgery.  I have a tutorial on how to improve outcome when "stuck" in a hospital ICU or orthopedic floor.....click the link I have great confidence in hypnotherapy especially in athletes! Steven Gurgevich from The Arizona Center for Integrative Medicine at University of Arizona is fantastic!
-God forbid....I know some athletes who stack roids....if you are on anything.  Let someone know, don't just detox cold, get primary to check your liver/kidney/adrenals and "T".  Need to maximize every organ in your body if you plan on asking the entire body to heal fast.   Unless you are a steroid free proathlete (Lance has done some great things for cancer survivors but I wonder if roid use prompted testicular cancer?)  Pro athletes are gifted humans....there was an EKG strip circulating around the primary care sports medicine community before Jordan was Jordan.  His preparticipation stress tests showed a resting heart rate of 40!!!  (as a reference, check your pulse rate now....probaly 80 right....imagine Michael Jordan's body was working off season at half the effort your body goes through in an average day).  Pros would probably heal up quick even with a bad diet!!!

See you next season!

Hitting the Wall

In any form of daily exercise, the body will have a stored amount of ATP to get by.   Your body has to maintain digestion, heart beat, contemplative thinking, locomotion, hormonal balance in addition to dealing with a daily exercise routine.  Humans have been able to condense all the above (not counting the daily exercise) to efficient levels of burning up calories.  It has been measured to be about 3-4 liters of water and 2000 calories daily.  That's an average and demands change depending on the amount of work, walking, disease your carry.  So with the old concept of "you burn up what you eat"....if you eat more than normal-it gets stored as fat.  If you are more active than normal, you maintain weight.  With the invention of social media, the couch potato routine has taken over many lives and obesity is rampant.  If you have never like exercise and then dive into it after 20years of nothing, you will either get hurt and fail, be lucky and find that you like running, of give up because you picked the wrong way to start.  Signing up at a gym that is having a sale is not the correct way to go that is unless you have some knowledge of successful lasting exercise in the past.  This does not mean signing up for a local fast pitch softball team since it was your love 20 years ago.  The routine has to be somewhat age specific and match the lifestyle/career.  (cant just quit your day job so we have to work it in)

Step in the power of an Exercise Physiologist.  As I have mentioned in previous blogs, experience speaks for itself.  A newly hired personal trainer at Planet Fitness may not have as much experience as an EP who took extra time in college to learn about the human body.  (I love Planet Fitness and work out regularly-however I also am a runner, bodybuilder, yoga instructor, and sports medicine physician so there is some training in my background)  Being accountable to a "3rd party" will increase the chances of success and having an Exercise Physiologist contemplate your BMI, Metabolic Rate, personal loves, career limitations, economic level, outdoor environment, fluctuating body dynamics and restrictions will take the guessing out and save time and money on your journey.  If you don't believe me, write down how many times over the last 10 years you tried to start an exercise program, how much it cost, how much you paid for medical insurance in the last 10 years and all your co pays for immediate care visits, cough and cold medicines, prescription medicines for ongoing medical disease (usually related to being overweight!!!)  Once you tally this up, call your local exercise physiologist (feel free to call my office 847 593 3330 and ask about price for Aimee Weber, EP at our Fit Academy) and find out about cost to enroll in a training program for 4 weeks.  (For an average American, if you make it past 4 weeks, there is a decent chance to continue to 6 months.  After 6 months, change is usually permanent.)  The total amount you spent over the last 10 years will overshadow the amount a good Exercise Physiologist will charge unless you hire someone like Jillian Micheals (she's not an EP).