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....