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). 
 

Plantar Fascitis

I did a 6 mile hike yesterday through the trails of McDowell Forest Preserve

see my hike on everytrail

and decided to go off trail at one point (not sure why) then ended up chasing this Great Horned Owl.  Problem -  I was wearing my Adidas Ax1 mid tops.   Not a good shoe for soft ground, padded with leaves, having to hop over fallen branches.  The mechanics are like stepping up high, over then down straight, deep and unstable (unlike post hole stepping in deep snow where the deep footprint will make a cast of you foot and stop the wobble-the leaves compressed under the new step are really slippery).  Because of 15minutes high stepping with the wrong shoes, I now have left heel pain. 

It can start with the scenario above. wrong shoes for event.  It can also be from breaking in new shoes, wearing shoes without insoles/arch supports, climbing steps, skipping rope, jumping/bounding with poor warm up, or new job/activity on concrete/uncushioned flooring.  Usually when I see patients, the event is not recalled.  Most people just complain they have been suffering for weeks to months and the first step of the morning is the worst.  If you look on the illustration above, the plantar fascia originates from the heel and inserts into the metatarsal heads (the ball of the foot).  It is a tough as nails ligament that is broad and long.  Supposed to serve as structural support to keep the heel bone (calcaneus) pulled into the metatarsals.  If you pull the two bones together, it creates an arch.  Arches in structures work to disperse load.  Think of big flatbed trucks you see on the road with nothing on them.  Usually the center of the flatbed is arched up a few degrees-made that way so when you place heavy equipment in the middle, the flatbed wont sag.  The beauty in human structure is with every step you take (Sting solo) the foot can disperse a little of the body weight to cause less damage over a variety of surfaces.  In my opinion, the best position of the foot for speed is up on the toes, with a natural arch, never letting the heel touch. (I witnessed this with working the Chicago Marathon medical tents.  I would listen for the start over the radio comm, then wait for the Kenyans to pass.  I can still see these tall, thin runners making no impact noise with their feet, high up on their toes, just floating through in a small privileged pack of humans that can run 26.2 miles in just over 120minutes....followed about 2-3 hours by "the pack".  A term I coined designating the majority of marathon newbies that are just in it to have fun.  Costumes, Elvis attire clad groups, the walking wounded.....but mostly flat footed runners who's footstep's sounds like someone taking a 10 pound fish and slamming it on the counter repeatedly)  Picture this style of running where all the weight of the body gets put into a heel that is essentially a short stubby stick with a rounded end.  Now picture the Kenyans running style landing on the ball of the foot, then the heel comes down (but doesn't touch) to decelerate the force of the body weight.  Get the picture? 

Most people will have ligaments that tolerate either style of walking/running.  The problem is if we are in the moment of doing any of the bad activities mentioned below the illustration, our plantar fascia gets stretched.  If we continue past the point of calf fatigue with prolonged sprint, jump or walk, the plantar fascia will start to develop microscopic tears (not painful during the event).  Continue on and the microscopic tears turn into big sudden tears (very painful).  This is a ligament under alot of tensile stretch so when you place a little cut-its like cutting a rubber band that is pulled to length.  Hard for ends of torn ligament to mend themselves when the torn ends are miles apart. So begins the accumulation of blood, injured ligament fibers that want to shorten, inflammation/microscopic swelling of local tissue to heal and the typical pain with first steps of the day, or first steps getting off the couch or chair.  Due to the vast amount of shoes with little to no arch support (especially women's shoes or men's work boots), the 8 hours of standing/walking usually results in the injured ligament getting pulled apart with each step of the day-not being allowed to heal. 


Treatment:  Allow it to heal........thank you for reading, have a good night and don't forget to tip your waiters and waitresses!!

It is harder than it sounds because in early stages, there is just pain in the am....although during a painless work-day, damage is still preventing repair.  For a runner it is slow death.....pain only in am or with certain activities but usually no pain with continued training.  But the "run" not only prevents healing, it causes more micro tears.  Until the overuse goes from pain after exercise to pain with exercise to pain with rest.  The Saguil Approach is to compress the time  frame of healing. 

1. Do no further harm.  Stop the offending activity (or cut it back by 20%).  Cross train or change your activities for short time. (2-4 weeks)
2. Improve healing, with proper nutrition.  Switch to the antiinflammatory diet  Even if not allergic or sensitive to gluten or dairy, I suggest all patients that are sick or injured to avoid the two groups for 2-4 weeks. 
3. Work to keep the ligament lengthened to the most pain free point to prevent recoil.  Ligament, tendon and muscle always want to keep a shortened position when injured/torn.  You don't want to stretch it to the point of more tears, just want to keep it from healing short and tight.  Note the pain that is usually felt in the am from being off feet for 6-8 hours.  Lying down in bed with feet up allows bones/muscles to relax and an arch to form, allowing the plantar fascia to shrink and heal over a few hours until full body weight is placed straight onto the heel with stepping off the bed......and....pop! All the healing/shortening overnight is re torn.  Wearing a night splint will keep the foot/arch at 90 degrees gently preventing any fiber shortening so even with healing overnight, first step doesn't pop any bridges formed facilitating healing of the heel. 
4. Supplements for improving body healing.  Turmeric/curcumin (see  video); magnesium glycinate or aspartate twice a day, omega 3 fish oil (see video); maximize vitamin D3 (see video); topical botanicals like Helicrysium. Tea Tree;  homeopathic's like arnica montana, Traumeel ointment; acupuncture; even physical therapy/chiropractic care to lengthen the opposing tendons to the heel like the Achilles/soleus, creation of temporary orthotics, increase endurance to the intrinsic foot muscles that help maintain the arch.
5. If it's bad enough, prescription oral antiinflammatories, topical antiinflammatories and yes, considering a steroid injection.  (You hobble in, get the shot, and walk out)....but don't be fooled, if we go prescription meds, numbers 1-4 still get initiated.)

If all the above fail, perhaps the diagnosis is wrong, MRI will be the next step.  Possibly second opinion from my like minded Chiropractic, Podiatric and Orthopedic Colleagues.

Taken from DrRic Frequently Asked Questions

So lesson from last time -"trust your gut feeling when someone hands you a bogus answer".   I expect my consultants to give an expert opinion on a diagnosis, then I expect them to get back to me.  Used to be in the 90's a phone call would be made after an evaluation and plan created.   I understand with low insurance reimbursement that docs have to move patients like cattle to pay the bills, call me old fashioned, I still expect when the door is closed, full attention to whom ever I send for second opinion . 

Here is the flipside:  my patients know I spent extra time after family practice residency in a sports medicine fellowship.  There are a handful of teaching centers in Illinois that many graduates apply for but only few get in.  Most of us in primary care sports medicine are dedicated athletes or just love the musculoskeletal part of healing/health.  I think it's fantastic to know how to prevent asthma attacks with changing shoulder and upper back strength or improve post partum sex with pelvic therapy.  (It aint just knowing how to test for an ACL tear or pop a shoulder back in)   Anyway.....I remember taking a state written exam one year with a bunch of docs, saw an old friend who graduated a year ahead of me.   I was psyched about my sportsmed fellowship and mentioned....."you should consider it as well for more clinical experience"  (your average family medicine residency entails 3 years of training and most programs offer 1 month of orthopedic assisting in surgery or a sports medicine rotation").   His reaction was "a sprain is a sprain".   I honored his opinion but thought to myself, no way am I going near his clinic with any body ache, sprain, tear or dismemberment.  It's good to know first aid, RICE and how to write a note for work/school ...but......spending 4 weeks with splints/narcotics and a pending second opinion vs just 1 week with a handicap when the injury should have been rehab-ed from the start is a gia-normous waste of time!!!!!  On top of that, after 2 weeks of time off the body has now deconditioned, gained a few pounds, developed constipation and drowsiness from the meds plus a little reactive depression from not being able to exercise.  My job as a doc is to help compress the time frame of healing.  Every case is a little different, every personality with its individual desires, every brain has its own tolerance to pain so not all treatment plans fit each person.   (I scoff at hand-outs that say do this 20 repetitions 3 times a day as the sole basis of "rehab")  It does make a difference to see a well trained doc for the symptoms suffered.  



Obviously I cant speak enough for the specialty of primary care sports medicine.  Even if you aren't an athlete, kinesiology/musculoskeletal medicine/disease pathology all play into designing the best way to get someone to optimal health.  (ie....if I have an out of control diabetic who is obese, I wont just say "lose weight by starting a walking program" ... I'd get physical therapy involved, make sure his/her nutrition knowledge is maximized for her activity, then steer her toward and exercise physiologist for brainstorming a sustainable fun calorie burning activity.)   True sports medicine looks deeper than just exercise injuries.   So how to choose a doctor:



1-Primary care sports medicine fellowship trained (just ask the office if the doc completed a fellowship)

2-Orthopedic surgery is different in that all specialist can "cut".  I like sending my patients to an orthopod that has trained specifically for the region of the body involved.  (ie.....one of my favorite shoulder guys is Tony Romeo from Rush/White Sox,  most young grads have gone through enough knee scopes that they all know about ACL/meniscus repairs-so for the knee guy I go for the best bedside manner, hand injuries still go preferentially to hand surgeons.)   A must for any of my "Pods" is good bedside manner.  There used to be a magnificent hand surgeon that worked down the street when I was with CDH.  His talent in the OR was famous.....so was his anger.   Dude used to throw sterile instruments to the ground and have a tantrum if everything wasnt perfect.  I guess thats ok if he is looking out for you but I dont use healers that hurt inside or outside the office.

3-Chiropractic physicians have excellent training around Illinois so I like the ones that listen in and get the true dynamics of the patients pain.  The chiros I use have turned pain/function around faster than patients going through conventional methods.  Dr Joe Musolino in my office does great work, graduate from National University in Lombard.  Great communicator with me and physical therapy and this is what gets people better fast-coordinated efforts between all providers.   You have to research training and experience and see how they are active in the community.   Just like medical schools, if the chiro school has been around for years and continues to expand curiculum, probably a good school.  On the flipside, I spoke with a DC that took care profighters in MMA, he just wanted to refer patients to me for writing scripts of anabolic steroids, saying alot of docs he refers to do it for him.  (obviously fell into the dark side of healing for the glory of rubbing shoulders with the rich and famous.....doesnt have to be that way-see my pics!)

4-Medical Acupuncturists are powerful in their own world of healing (and have been for the last 2500 years)  When combined with conventional healing, I consider bringing them in like calling a left handed pitcher to a tie game.  For any injury that has plateaued or if an athlete needs to get better fast for a fight, game or match in 2 weeks-call in the needle doc!   I originally studied medical acupuncture at UCLA to see if I could speed up healing while waiting for the physical therapy HMO referal to be approved.  When I used it, it worked like a charm, sometime the patients would get better and not need therapy or surgery second opinion any more.  Ahh...unfortunately, insurance caught on and discontinued covering acupuncture as a benefit so I had to retire my skill.  (Only bring them out for special cases like in getting my pro MMA fighters to relax before a fight....see my pics!)
 

So if you are injured at work, in a league event, or during training; dont be embarassed to ask your provider what kind of training s/he went through.   If it seems like the injury is taking longer than expected, seek out one of us (see above) and get better faster!!!!  A "sprain is not just a sprain".  

Colorado Springs Olympic Training Center

Illinois Gynmastics Association Bravo Meet

Chris Chelios ex-Chicago Blackhawks

David Reid Gold Medalist 1996

DonWilson martial arts 1990's

Sean Murnane Chicago Bears

Felice Herrig Bellatore Fighter (the non athlete is Julian from B96 morning radio show jumped into the pic as he was leaving my office)

DrRic Post Marathon Recovery

    The Chicago Marathon finished last weekend. Good news is I havent had too many walking wounded come in. (Working medical tent at the end, most injured will come in walking well but draped in aluminum and assisted by a volunteer) Finishing is a great accomplishment but at a price. I attribute my finishing the '09 and '10 events with yoga, good nutrition and anti-inflammatory supplement rescue. (...and that was with only a few days of summer pre-race training. Disclaimer! I do not suggest entering into a marathon without proper training/coaching-I just did it my way to prove a point that the practice of clean living allows the body to heal itself insanely fast! If in Chicago, please visit CARAruns.org for proper training I'll tell you about my patient who was unconscious for 2 days later)

    So for pain I suggest adding Turmeric. Love this stuff! Great reproducible studies now out (did a post back in 2008 just suggesting herbal use based on anecdote....now we have data!!!) Janet Funk from UofAz researched the effects of turmeric on arthritis and found it was critical to have the combination of turmeric and black pepper (piperine) for optimal absorption from the gut. So although I have suggested New Chapter in the past, I called the company and asked about their data on absorption and no one gave a straight answer on if their "super critical" prep technique helped the curcumin get into the body. (Sorry for the technical mubojumbo but data is essential to make proper recommendations for my patients-learned that from Andy Weil). There are a few formulations that have the combo together Source Naturals is "ok", but around my area GAIA brand is available at Whole Foods Market and Fruitful Yield. I usually go for high dose at 1 cap 4 times daily for 3-5 days. Magnesium glycinate or oxide is great for muscle spasm (blood tests for proper mag level stinks unless you do an RBC/erythrocyte testing) This one is sensitive as it can cause problems with diarrhea or palpitations if taking too much. Usually 400mg twice a day is good. (caution with thyroid hormone users in that it will mess around with your medicine so dont take together) Make sure you are on Vitamin D3 1000IU twice a day (at the least......and I usually burst high at 4000-5000IU per day) and take it with Omega 3 fish oil. Omega3 I feel is always necessary for balancing omega6 intake for an average American diet. For the 7-10 days following a hard work out, stay aggressively on an anti-inflammatory diet and avoid dairy. (Even if you aren't lactose intolerant, I feel dairy is just to much of a wild card in eliciting a reaction-whether bloating and diarrhea or just slowing healing time). In the first days of crossing the finish line, push Fluid and pee like a race horse. Nothing worse than asking the body to get byproducts of inflammation out from the muscle fiber, through the vascular system and into the liver for breakdown when the vascular space is bone dry. Remember, as a culture, we abuse hydration by ignoring thirst (especially at work), over indulging in caffeine and alcohol (diuretics), and opting for sugary bottled drinks instead of a glass of water (reverse osmosis carbon filtered). So push fluid to the tune of 3 L/daily (13 cups) for men and 2.2 L/daily (9 cups) for women at the least! (8 - 8ounce glasses/daily is oldschool). If it isn't palatable, drop an Airborne fizz tab into the bottle/glass and keep it cool. Cut back at dinner time (6pm) or you will be cursing me as your dream state gets interrupted with a trip to the urinal/toilet.    (There is also the IV therapy option-by coming into the office for a "Meyers Cocktail".   Essentially a whole bunch of vitamins in a bag of fluid we place directly into the vein to bypass an irritated stomach and insure 100% absorption to the areas of inflammation. 

    For muscle stiffness I like manual healing. From massage therapy, to manual therapy by physical therapists to acupuncture/yoga healing. This post marathon time period when I highly suggest investing in a manual healer. Acupuncture can sometimes be reimbursed by HSA or flexbenefit spending accounts (with a prescription), physical therapy is usually covered by medical insurance (with a prescription), chiropractice therapy is usually covered by medical insurance, massage comes out of your wallet. Movement/contraction of muscle helps to get out the lactic acid and keep the stretch receptors from spasming and getting tighter. Moving your own joints when in pain is difficult to do on a regular basis. Get someone to move for you! One way to "self massage", is a technique called Abyangha. Known in yoga circles, the technique is to move "energy" to heal better and apply a thin layer of warm oil to the body. Those who have been to a good massage therapist know the well versed healer will choose oil depending on the mood/nose of the patient/client. In the case of recovering after a tough work out, I would use sesame seed oil, olive oil, apricot kernel oil or lavendar/sandalwood essential oil.  (I prefer PanAway by Young Living for my sorest of sore spots)  Apply the oil warmed from "tips to heart"; start at the finger and toe tips and firmly apply/knead the oil into the skin with long strokes in the direction of "pushing" the lactic acid out of the muscle back to the heart. (actually pushing lymph fluid from out of the extracellular space back into the vascular system to be recirculated by the pump). For the true technique, the oil is left on. My realworld application is to keep the oil on for at least 10 minutes, wrap with a comfortable robe, have a cup of tea then shower off as usual. Not only does this help with sore muscles but great for dry skin winter itch.

    Finally, mornings are usually met with the tightest knees, hamstrings and calves. Like my plantar fascitis sufferers, before you move out of bed, warm up/wiggle the small joints (fingers toes), circle the medium size joints (wrists ankles), flex and extend the big joints (elbows and knees) for 10-20 seconds each, then sit up and take your first steps of the day. Been there, done that and still in pain? Get to a sports medicine specialist ASAP! Running on an injury changes the dynamics of your gait and you will strain or sprain an unrelated body part and have to deal with another injury. See my post on how to pick a healthcare provider. Happy running!

Numbness after Whiplash

I find for the most part, upper back spasm and neck pain from trauma always get better faster with the same suggestions. Remember, every body type, age and sex has their idiosyncracies so treatments vary. Here is an excerpt from a recent communication with a patient:


Hello Mr S

I was contemplating S's symptoms and I have some ideas. First if the symptoms havent changed, since I saw her, great! The usual symptoms of numbness tingling or pain and dysfunction are attributed to trigger point irritability. The only reference most of the medical community will use for trigger points is with fibromyalgia so if you talk to another MD, dont be surprised they may no agree with me. If trigger points are irritated, my patients will have shooting, numbness or tingling from the neck or shoulder down to anywhere in the hand, sometimes specifically to a finger. My neurology counterparts will try to associate the distribution of the symptoms to a specific 'dermatome' to decide which level disc from the cervical spine the spinal column is suffering. This is good for mapping exactly where the etiology is if a surgeon is going to 'build up a disc' or if a pain doc/neurologist is to inject steroids to around the irritated nerve to speed up healing. In the end, S isnt that bad yet.(unless something has changed)

The two problems I see hindering quick resolution are:
1-Age of the injured. Although a healthier than normal 50 year old, healing will still be slower than an average 20 yearold. 20 year olds going through trigger point recovery sometimes 3 weeks, females usually longer than males, (not sure why but I find it is also associated with the reason why women prdominately are the ones afflicted with Fibromyalgia).
2-S's posture. This is nothing bad and I mentioned this to sensei already, sometimes we are used to a certain posture for years, kinda like flat feet. But....when injury occurs to the same person, healing can be prolonged due to the 'flat feet' or rolled forward shoulders. I typically see butterfly stroke swimmers have more problems recovering from trapezius injury or neck spasm than free style swimmers due to the forward rolled shoulders and the 'collapse' of the thoracic outlet. Any tightening to the thoracic outlet will potentially pinch the nerve plexus passing through it. http://en.wikipedia.org/wiki/File:Gray808.png When the plexus is irritated, a nerve pinching can and usually results in numbness or tingling or shooting pain and occasionally weakness. (btw, if it ever gets to weakness, time to throw in the towel and save the nerve by surgically decompressing it)

The two benefits I see are:
1- S's health level. Good diet, good supplements, good awareness of health.
2- S's training. Fairly better range of motion with the upper extremity than average female her age.

I havent done much acupuncture these days since I have a full patient schedule and an acupuncturist at the office but remember......this was an car accident so you can save all bills and give them to the offender's car insurance. I would still suggest Frank Grill at Naperville Acupuncture Center
http://www.dupage-acupuncture.com/ or Dr Zu http://firsthealthassociates.com/custom_content/c_115228_yu_zhu_lac_omd.html at my office. The only problem is you have to pay upfront to these folks then submit and await reimbursement from car insurance. I feel this route would help and speed up recovery. I would also suggest massage therapy, deep tissue regularly to loosen and care for the trapezius spasm. (again save the bills) I have an excellent massage therapist that works out of Turner Rehab on Eola.
http://jadamskraus.wordpress.com/about/ and she may be able to help with alignment principals of yoga to help reposition the cervical/thoracic spine and scapula to help open the thoracic outlet

I would always increase levels of
-vitamin d3 to 2000IU twice a day (unless recent blood levels havenot been drawn) with a fatty meal
-make sure there is a supplemental amount of calcium to 1000 mg daily
-cut out dairy for 2-3 weeks, ok to substitute with soy (initially a total of a cup daily to accomodate for the new protein being introduced to the gut (gas) for a week)
-turmeric three times a day (I believe the most potent antiinflammatory veggie available to man) I like New Chapter Turmeric or Zyflamend - (found at most Whole Foods Market) +/- 400mg three times a day
-valerian at three times a day as long as no sleepiness is felt, it is great for sleep but in europe great as well for relaxing anxiety or muscle.
-magnesium if not checked is also helpful if there is a sense of tight musculature, but I remember sensei didnt feel she was tight, right? 400mg daily is good. I have used much higher but have to be careful with slower kidneys. Watch for diarrhea.
-topical use of tea tree oil, helicrysium, arnica, Traumeel (homeopathic) or cod liver oil before deep tissue or just three times a day
-physical therapy should be considered since it can be applied to a regular insurance card, (just need a script from me-let me know if you decide yes) and if trained correctly, the pt can reduce alot of spasm just with proper posture cues, kineseo taping or body alignment training,and scapular stability exercises -Mary Rachford at Naperville PT http://www.napervillept.com/ also has been trained with ASTYM-kinda like a modern version of gua sha or chinese skin scraping and finally use of transdermal steroid to locally bust up inflammation to trigger points with ultrasound or low intensity electricity.
-finally, do no further harm with overhead work or carrying on same side

This will help, just let me know what you need from me
always at your service-
Ric Saguil

BTW-I will be giving a lecture at the Whole Foods Market in Schaumburg on March 26th saturday on Food Choices for helping Inflammation Resolve

11 23 12 addendum: comment was sent in that numbness could be due to impingement of nerve tissue.  If I see anyone with severe pain, loss of function, unresponsiveness to standard treatment, I would get mapping (MRI and EMG) to see if the symptoms are from major structural damage.  On the other hand, if symptoms are mild, physical exam is reassuring and problem is not chronic-proceed with what was mentioned in my blog.  The majority of evaluations in all offices are muscular causes with an incidental bulging disc on MRI.  The above treatments are good for muscular causes and still helpful for impingement (other) causes.  I have great Neurosurgery collegues/friends who know when and how to surgically fix discs with minimal residual damage.  If I am the doc responsible for your health, and if I didnt consider every avenue of diagnosis, treatment and possible side effects, I wouldnt be doing my job.  So good point Mr T. 

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.