Unboxing 5HTP

Exercise Intensity

CoachRic's guide to advancing your activity:

1-Determine your Base-everyone starts at a different level of fitness, age, experience, limiting disease.  Expectation is to improve endurance, strength and speed over a period of time.  Rest should also be calculated into your exercise planning.  (there should be a fail safe duration of time in case of "push and crash"-see last paragraph)

-Assessment of TARGET HEART RATE (sometimes known as lactic acid threshold)

(calculate Maximal Heart Rate-MHR = 220-age)

Blue zone for warm up and recovery ................50-60% of MHR

Green zone for fundamental endurance ............60-70% of MHR

Yellow zone for active endurance.  ...................70-80% of MHR

Orange zone for resistance.  ..............................80-90% of MHR

Red zone heavy resistance. .............................90-100% of MHR (difficult to measure)

-Rate of Perceived Exertion can also be used
1   rest
2   very light
3   light
4   fairly light
5   somewhat hard
6
7   hard
8   extremely hard
9   very hard
10 maximum exhertion
(note RPE is a bit harder to dial in as it is very subjective BUT it serves as being directional to advance effort)

2-Determine fitness goals, calendar deadlines and health outcome goals. Advance in a linear or cyclic approach to pushing to the point of "uncomfortable muscle pain" and holding for a preset amount of time then rest.  Not regarding repetitions or sets... this is just the sessions per week.  Ultimate goal is to drive enough muscle work to stimulate mitochondrial bio genesis WITHOUT hitting the wall and crashing.  Avoiding the injury of hitting the wall will keep a time efficient plan to get to summit.  For Chicagoans, I expect to take advantage of spring summer and early fall and get as close to goals then stabilize and hold through out winter months until the plan for next year.  

GOALS:

-Build Muscle

-Lose Weight

-Improve Performance (get around a plateau)

-Balance/Reverse Disease

3-Overload / Adapt / Progress within each Phase

(even with no desire to add resistance, cardio training itself can lead to overuse injury)

Phase 1-work on deficiency of endurance, strength, flexibility, imbalance

-steady linear progression during this phase finding proper rest, nutrition, exercise type

Phase 2-work on undulating progression of cardio/endurance/overload 

-more specific for end goal / summit

-adjust load, tempo, volume, rest time and weekly order of exercise

Phase 3-testing efficacy of training in mock end goal / summit 

-care for co morbid conditions of obese, age, prior injury and medical disease

The Saguil Approach is to push skeletal muscle / cardiovascular fitness / immune system to its limit.

In some cases disease symptoms must be controlled first with aggressive medical management.  Often before starting with Phase 1, 

-Physical therapy will have to be called in to help balance skeletal alignment and regional dyskinesia.  -Psychological therapy will be just as crucial to maximize morale and endure the trials of work and sacrifice 

-Nutritional therapy would be a crucial asset during Phase 2 as we find balance with attaining maximal heart rate and building muscle while staving off pain and not adding to central fat.

I feel when the heart brain and muscle are fine tuned to maximize on cellular / metabolic flexibly, the immune system will be reset and autophagy will clean up misfiring cells and inflammation.

-Coaches will be hand picked, I act as Captain and the team is there to guide you to success.

Gonna make you sweat...

                                 SWEAT

With a recent interview during patient hours, I had gone through my usual Q&A to develop a picture of the 2nd person in the room.  One of my pillars to a balanced antiinflammatory lifestyle change is activity.  EVERYONE HAS TO MOVE....in the US we conceptualize walking as a chore thinking there is status in not having to walk so far from the front door or being at the back of the line or being able to watch 200 channels after a huge dinner, paying for your pre-made food instead of having to make it or chop veggies or cook from scratch.
My patient said he goes to the gym for 60-75 min about 3 x weekly.  NICE!!! Then I ask what are the activities he relies on (thinking I may be able to change or rearrange his routine to get the most his time in the gym).  He said 15minutes is spent in the sauna, another 15 spent in the whirlpool...then he gets on the treadmill or uses machines.   So you are thinking, 30minutes getting warm, then the rest of the time expending energy on the gym floor.  Fits into the AHA's recommendations of 30min 3-5 days a week.  BUT...this is a business owner that has 2 jobs and works around 60-70 hours a week and shoots for 6-8 hours of sleep nightly.  Even with his enjoyment of heat and concept of relating sweating as a form of exercise....this is where the life coach in me says to better utilize total hours per week, cut out the heat and try to condition the cardiovascular system to tolerate HIIT, (driving the heart rate high in a short amount of time and sustaining it for 30min -DONE!)...save time in the gym, get sweaty and with the 90minutes of "freed up time" per week, we can dive into a mindful practice development or enjoy a walk or family time.

(So I like using the American Heart Associations saying of minimum activity is 3-5 days a week of 30min of moderate intensity exercise weekly. )

So speaking of the cardiovascular system, when the heart beats faster than resting state, it is a muscle and muscle generates heat.  The reason the heart beats fast is to supply freshly oxygenated blood to muscles that are moving.  All this muscle heat has to be offloaded for fear that the brain will heat up to high temps - and result in a seizure.  One way to neutralize temp, SWEAT.  Perspiration moves water to skin layer and evaporation is cooling.  Some proponents of detoxing say a lot of toxins will leave the body with sweat but ....regarding weight.  NO overall change when you reload the fluid you sweat out in the gym over the course of the next 12 hours.

1-sweating ok (unless you are on a water pill at which point you can drop blood volume too fast)
2-perceived exertion of sweating should be associated with breath and pulse rate
3-walk when ever you can, stand instead of sit, feel the body high of moving fast for short times
4-tie in healthy eating to healthy activity to healthy mindful practice (stillness in silence )
5-HIRE a COACH if you are stagnant with what you do / bored / plateaued on benefits

Hormones like a teenager

In my prime-I was a muscle head.  Lived in Wildwood New Jersey.  Had 3 roommates (1 bartender and 2 bouncers).  Worked out at Atilis Gym in 1982, that summer the gym owners asked me to compete in a Mr East Coast and Mr Natural New Jersey.  I was 18 and didn't give a sh*t so I joined and won both (teenage divisions).  I lifted weights with some Venice beach-like-male-airheads and refined my "Muscle and Fitness magazine" body building movements.  (Joe Weider's publication was a bible back then)

I seemed to develop a lot of muscle mass with what I was taught so I took it with me to college and later.  I believe when we adapt a "routine" that: works, doesn't cause injury and gives size gains.....that becomes religion for the remainder of our exercise lives (at least for guys).  The lucky ones can still continue with the "usual" exercises no matter what age (maybe tailoring the routine to help with weight gain).  The not so lucky end up in physical therapy for some age related ache and are given a 3-6 week sentence with a physical therapist.  From that point on, free time limitations and achey reminders keep the "new routine" fresh.    

I stumbled upon alternative and complementary therapies when I tried to avoid rotator cuff surgery from a rock climbing injury in my 40's.  I did my own rehab and kept it to bare essential movements to maximize time in the gym and still get a "pump".  (can't let go of the feeling to muscle fiber with targeted movements with weights!!)  I beat the knife but it took a few years; I also dived into marathon running, yoga and more recently hiking.  Still can't stay away from trying to chisel a little muscle definition-so I have been doing this truncated weight/cardio work out (called peripheral heart action or circuit weight training before there was cross fit) guys do and getting by to work the heart and keep fit.

I started a new chapter in my life by signing a contract to go back to running a primary care office like I did in the 90's.  (worked in family medicine and carved a niche with my sports medicine clinic in Wheaton).  This week I decided to go back to using cables to work my shoulders.   [In a gym there are free weights, Nautilus-type machines to isolate body parts, universal cable machines for some restricted movement then Smith Machines for universal bars and big plates (wagon wheels).  So there I was.....pushing the envelope with repetitions, grunting from pain (had my bluetooth headsets on) and since it was empty-running between 3 stations back to back like a college crew teams would do.  As I finish my last of 3 giant sets, I feel a great pump to delts and traps....no ache...good heart rate....well targeted and I'm done!!  It just hit me, I was so used to the bare basics of quick power lifting movements that I forgot my old techniques of fine muscle tuning.  The feeling brought me right back to days at the gym in Wildwood NJ!!  Then I look up and see:

LOL!!!!

Lose weight; change your life; don't get hurt.

Spring is here and most people are scrambling to start dieting.  If you are like everyone else playing catch up, don't expect to do things the same way this year.  The 2014 snow season kept most runners in, most drivers delayed, most exercisers bundled up.  The usual dietary reflex in the deepest cold is to seek nutrient dense comfort foods.  In other words, the bears are coming out of the den with an extra padding of fat this year.  It just so happens  there are also 2 drugs that are building up steam as part of the "cheat-code" for initiating weight loss.  Qsymia and Belviq were released in mid to late 2013 (and so far no deaths!!).  Of course the most important impact anyone can have to lasting weight control is total lifestyle change.
I maintain my patients seek to address 3 components of life:

Thinking

Eating

Activity

(see my video)

The eating part everyone says "I know what to do, I just have to do it".  I disagree 100%!!!  If adopting a nutritional change was as easy as shopping the periphery of the grocery and choosing labels of low fat, our nation would be lean and healthy.  The World Health Organization published a controversial ranking of health throughout the world in 2000 and the US was 37th out of 190 countries (but we spent the most money per person in the world).  Seems out of proportion but just look at the check out line and notice how many people look overweight (1 in 3).  I just came back from an indoor water park and it was disappointing to see out of shape kids (waiting a few minutes I would see the inspirational out of shape parent float by) but then I thought this was job security for me.  However I refuse to just prescribe medicines and watch people become behaviorally addicted to weight loss drugs.  Anyone that goes to see me out of network knows if you want meds like phentermine, I must hear from your team of coaches to make sure I agree you are a "responsible adult".  When I hear the catch phrase above, it usually leads my brain to image how this person will look in 10 years.  (It's always the same-10 pounds heavier with 3 new medicines and 1 new surgical disease diagnostic procedure).  It takes more than just reading a few chapters from an author and experiencing 10 pounds of fat burning in 2 weeks back in college days to say you know what works for you.  In my short 20+ years of medicine, I have learned that community can overcome disease but disease can overcome the individual.  We have all the answers on how humans work (down the the DNA sequence) but a patient requires the knowledge to be applied in an individual designed lifestyle plan.  There is alot of great reproducible evidence out there (pubmed, google scholar) but I find myself "piece mealing" snippets of plans together to initiate, modify and maintain the routines people come in to see me for.  And it usually has to be reformulated in stages.  The "giving spirit" in me tries to keep people from spending their hard earned money on me and rather on nutrition, exercise and meditation coaches.  Infallibly, the plan works for a while but has to be reformulated as the goal was achieved and the next pinnacle has to be planned. I guess this is where most people throw the towel in, they hit a plateau, don't see further gains and just regress back to previous life/weight with disappointment.  So they tasted victory but lost the focus to maintain it, and the picture of summiting Mt Everest sticks in the memory more so than the pain of losing all your fingers and toes.

"I know what to do".   I believe most people with guidance can daisy chain small bursts of change to ultimately get to a goal that is healthy and rewarding.  It takes the right tweek from the right specialist to hit the next pinnacle.  I dont mean a medical specialist, this is more of a makeover specialist-the specific trained coach that can overcome the specific obstacle we run into.  (...could be flexibility, nutrition, self esteem, spouse issues, injury, food allergy....we are multifaceted and complex and problem solving requires a community of healers).  Currently, my best vaccine for the disease of weight gain is listening.  I don't mean you sit on a couch and regurgitate all frustrations to me-that would be a waste of my time and your money. Quid pro quo interviewing is the best way to get me started in creating a template for change.  Unfortunately this takes an average of 60-90 minutes for me while medical insurance has been chipping away at the proverbial office visit (13 minutes total to break even).  Those basic areas of change do require some trust.  When people say they know what to do - I translate that to mean they are not willing to change.  Experimentation is hard because it requires a step into the unknown but if I can summon the help of Jim Fixx, Linus Pauling, Atkins, Benson, Ornish, Weil, Chopra......there will be a wealth of knowledge to help catch you when you fall; (everyone falls!!)

When I hear "I know I need help", the creativity of my right brain takes the logic from my left brain a beautiful painting is created.  

To experience the Saguil Approach to lifestyle change, sign up for the April lecture at Advocate Sherman Hospital in Elgin (Randall Rd and 90)  Link to Event Tickets

Back pain from Shoveling

The last 10 days has been a massive winter "dump".  The snow fall seems un-ending and I have been getting alot of great outdoor time.  I love the clean look of a driveway after shoveling but hate that one crack in the sidewalk that catches my shovel tip just as I am going full speed with a big avalanche.  Well I also noted when my fingertips were painful, throbbing, I didn't realize my back was telling me "take a break!!!".  My mind was saying oh, just finish the last part of your driveway and it will stay dry magically forever.  Pain is usually delayed like whiplash....the next morning as the eyes open and the first step of the day is met with "whoa....did I sleep wrong?....oh....I shoveled yesterday!"  Then the realization is that it's still snowing so you have to do it again.
Muscle spasm if the activity is aggressive and blunt, will be felt accordingly at the time.  If activity is long and repetitive, the pain and inflammation is delayed up to 2-3 days.  It doesn't have to be an ache in one spot, pain can be a flare up of an old pinched nerve/bulging disc type pain.
The way the back is made is skin to outer layer, muscle covering (epimysium), muscle, fascia and bone.  The muscle is built to contract repetitively for life (think of the heart that beats every second for your entire life)  The problem our back muscles come into is the brain gets "superman strength" when reasoning about taking a break vs getting the job done now and going onto another chore.  With fatigue the muscle can still be stimulated to contract and do the job but lactic acid will accumulate, energy (ATP) will be used up, and some tendon fibers will tear (microscopically) and imbibe blood/edema slowly (versus a skin cut where blood comes out fast).  With a slow leak throughout broad low back muscle, swelling and stiffness will occur after about 12-24 hours.  Usually felt next morning.....same concept as whip lash.  With my previous post on whip last, there can always be pinched nerves, broken back bones, herniated discs....but those are usually sudden onset.  (only way to tell is to see a professional)
My best advise is to
1-do no further harm, lay off further shoveling, no exercise for 3 days, take brakes if you have a sitting job.
2-start with antiinflammatories immediately, that could be supplements like turmeric/magnesium, topicals like helicrysium/capsaisin/wintergreen, or prescription medicines/muscle relaxers/NSAIDS/narcotic pain relief.
3-get hands on healing, your choice of chiropractor, massage therapist, physical therapist, a relative with strong hands
4-raise the flag and see an MD/DO if urine or bowel incontinence occurs, pain doesn't allow sleep, numbness or tingling start, cant get out of bed, symptoms longer than 3 days

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). 
 

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.

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)

Tennis elbow

Same dojo new injury;
3rd ranked female judo player had problem with her shoulder. MRI shows glenolabral tear(shoulder cartilage tear) and her pain is with stretching of her capsule only (pain to the front of her shoulder with judo throwing). Sent her to physical therapy, worked on flexibility to the now tight shoulder is quiet but the forearm is killing her. No apparent trauma but getting to point of pain with gripping. World competition is in january. I wanted to try conservative therapy but competition is too close. In this event, acupuncture would be the way I would have tried to move the pain/stuck energy. This would be what the "Saguil Approach" is about, knowing all the full options including alternative and surgical. We will try a steriod injection tommorrow and continue with the treatment of shoulder and forearm rehab, acupuncture deep tissue massage and antiiflammatory. In acupuncture terms....the shoulder point of pain and elbow point of pain and all in the lung meridia. I hope we can continue with stimulating the points to move the energy. I also asked her to get on an antiinflammatory diet but not sure how she is keeping up.

We'll see....