Coming out

Went to the dojo and had our sensei holding his right shoulder. Told himn I was a sportsmedicine doc and eventually got to the point of telling him it was a small entrapment of the rotator cuff. Told him a few things to do and eventually he told me of a student who was very competitive and suffering from a right shoulder issue. MRI showed a bucket handle tear to the labrum. Not a good thing to have. In most sportsmedicine circles....this injury is the reason many orthopedic surgeons scope shoulders. I am also in eastern medicine and believe the body can heal anything(as long as there is time). On eval, the shoulder was loose and there was "apprehension sign" with me attempting to push it out of socket. This was the recreation of her pain. It may not be the tear of the cartilage but more the looseness to the shoulder htat gives her the problem. She has good insurance but doesn't want to be laid up with the post op surgery right now. She never went back to the doc and has just been handling the issue/ pain. Sensei says she is and up and coming judo practitioner and very competitive on the national level. I told her about and antiinflammatory diet, ice, strengthening exercises and acupuncture. I believe there is a great chance to improve....told her it can be up to 6 months with a shoulder trained physical therapist but we are on our way. Worst case would be if she can't wait.....I send her to my surgical friends and we cut.

The reason I speak of this is many people will trust their doctor, who refers straight to ortho. In western medicine, specialist base treatment plans on study outcomes. They do what they do best and cut. Sometimes its worth it for patient and doctor to think outside the normal western medicine box and formulate plans that range from conservative to ultra aggressive and dive 100% into either by diet rest restriction therapy or surgery.

teenage knee

As I was finishing my boxing class, Mike was wrapping up a guys wrist and asked if I could do it for him. The gentleman told me he had a kid in highschool who was suffering from knee pain for a while. He was playing football at Waubonsie Valley HS and even in the post season, still suffering. Immediately, thoughts went to a diagnosis of Osgood Schlatter Disease. Sounds real fancy but essentially a growth issue. I asked dad if he had a bump to the tibia, he said yes, then asked if he grew few inches in the last year and he said yes, finally asked if there were any major injuries and he said no.

In a article about knees I did earlier, I explained how the mechanics of a knee cap-(patella) work in an older knee, (as if 30-40 is older!). Now we are talking about the same tibia, patellar tendon, patella and quadriceps but its in the bones of a growing boy that is doing alot of sprinting "off the line" in football. The big difference is not the sprinting but the bone. The young bone has growth plates to each end that allow for lengthening over the course of several years. If you look to the illustration at the top of the page, mature bone that has stopped growing has no plates at the end so the patellar tendon, attaches right into the bone. The patellar tendon to a growing boy attaches to the growth plate:




If there is enough "pull" from the quad during repetitive sprinting, the quad, patellar tendon complex will lift the growth plate up off the long bone and result in a "bump" to the knee. Usually very painful to touch and the first thing that hits the ground when kneeling. Even in the case of the nonathlete, if there is no sprinting, the quad and patellar tendon can just be overly tight, constantly pulling on the growth plate until it also lifts it up causing the "bump".




The older athlete will go through the same forces with sprinting or overly tight quads but since there is no growth plate, this overuse injury usually ends up causing jumpers knee or patellar tendinitis. The weak link in the adult athlete is no longer the growth plate but now the patellar tendon itself.

Immediate treatment is hold off from further sprinting or jumping, ice therapy, antiinflammatories, quadriceps flexibility, and sometimes a "chopats strap" (many gymnasts where this) helps.

Check your pulse

While warming up for my boxing class at Contender Boxing and Fitness, I watched Mike take some "non-fighters" through a cardio class. He was working them very hard and there was some sweat flowing in the gym! Obviously these guys were in good condition but I asked Mike if they monitor pulses. I said it would be a good idea for people to know how to do this. It's a standard that is easy, cheap and a good "barometer" to let the patient, client and the trainer know exactly how much this person is working his or her heart. Some people have a good will and don't want to give up even if the heart is working a little too much. For an untrained or nonconditioned new athlete, this could be a problem especially with the older than 40 crowd.

The American Heart Association suggests:

Age/ Recommended HR/ Max HR

20 years/ 100–170beats per minute/ 200 beats per minute
25 years/ 98–166 beats per minute/ 195 beats per minute
30 years/ 95–162 beats per minute/ 190 beats per minute
35 years/ 93–157 beats per minute/ 185 beats per minute
40 years/ 90–153 beats per minute/ 180 beats per minute
45 years/ 88–149 beats per minute/ 175 beats per minute
50 years/ 85–145 beats per minute/ 170 beats per minute
55 years/ 83–140 beats per minute/ 165 beats per minute
60 years/ 80–136 beats per minute/ 160 beats per minute
65 years/ 78–132 beats per minute/ 155 beats per minute
70 years/ 75–128 beats per minute/ 150 beats per minute

Your maximum heart rate is about 220 minus your age. The figures above are averages, so use them as general guidelines.

I tell my patients to try and hit the lower number of the pulse range for 20 minutes of exercise checking every 5 minutes for about 12 trips to the gym. After that work up to add 20 beats per minute every 2 months (conservative) until you have reached the highest number of the recommended HR. If you can maintain this for 20 minutes 3 times a week, your heart will be fit. (assuming no other risks exist like breathing problems, seizures, diabetes, stroke...which should be evaluated and cleared first before starting an exercise program.)

I like the watches that check pulse but they are at a price. Personally, I use the Suunto T6. Others that are popular are the Polar, Citizen, Timex, Nike....it all depends on what other goodies you want with the pulse monitor, (distance, direction, gps, barometric pressure, software fitness analyzer). My goal is just conditioning, I'm 45 shooting for 160-170 for 20-30 minutes. This is over an above the recommended levels but I have also been cleared of any medical illness with stress testing, heart scans and cholesterol fractionation.

Good old fashioned finger pulse checks are cheapest, one work of caution is checking the neck pulses. There is a sensitive area in the neck called the carotid bulb. In some people, this could be very sensitive and cause a "vasovagal" reaction like that of a jiu jitsu lock. It may be a bigger artery to find but probably good to avoid in anyone over 40y/o.

Exercise Safe! Push it to the limit! Stay Healthy!

capsicum

There's a great topical drug that helps facilitate back pain control. We used to use it for Shingles (a form of viral herpes skin infections) which is very painful and sometimes leads to morphine sulfate use for control of pain. It's uses have been extended to standard pain issues. Many people will see it in the pharmacy next to the Icy Hot or Tiger Balm. Most folks pass right by it since packaging isn't eye catching. I've seen several great forms of capsaisin in the form of Zostrix cream (my personal favorite in the emergency room for people with back pain or neck pain) and salonpas adhesive patches (my personal favorite -most of my older relatives in the Philippines used to walk around with these pads stuck to them and before medical school I used to think of it a some form of voodoo). Any topical pain reliever is made to cause a sensation to the skin that will overpower normal sensation. Example, when a baby is given a cap/hat for the first time, kid usually pulls it off since it doesn't feel right. Soon after trying over and over again, the baby gets used to it. When applying zostrix to skin, it burns. It's a dull sensation but the feeling is like applying hot pepper to skin. Actually, the active ingredient is from hot peppers. The feeling is distracting to the person in pain and one of the methods of relief is to make them think about something else....well, hot pepper will make you do that!

The other relief in pain is more scientific and separates this component from the Icy Hots and Tiger Balms. RCT (randomized clinical trials) performed with capsicum the active ingredient in capsaisin cream, revealed it reduced the amount of Substance P to the area it's applied to. Substance P is a neurotransmitter found in pain fibers and when depleated, pain fibers don't fire to send messages of pain to the brain. Overall, pain sensation if reduced. Practical problem for the cream has always been accidentally applying too much or getting it in the eyes. One of the reasons I like the patches of Salonpas (walgreens) is you could cut as much of a size as you like and not get the hands greasy. Caution: there are salonpas patches at walgreens that don't have capsicum so read ingredients before you buy.

The place it comes from is the seed and little ribs found in red peppers. Different peppers have different ratings usually measured in Scoville heat units (SHU). This rating is usually talked about during the pepper eating contests of Texas. (some people have too much free time although I find myself attracted to watching this and hotdog eating contests while riding my stationary bike at Planet Fitness)

So far, I have not read any info on chronic use and becoming accomodated to it. There have been no other problems aside from people with allergies to peppers using it without reading ingredients. The Saguil Approach to proper use is to apply it 4 times a day and after achieving pain relief, work to stretch the triggered/spasmed muscle. Usually it will be painful at first like any stretch done properly. If continued on a regular basis, the stretch will lengthen muscle fiber and help overall to reduce pain and inoperability of the muscle causing the pain. More stretching leads to more blood flow to injured muscle and faster healing. Alone it may work for small spasms, for larger and more chronic areas, it would be an excellent adjunct to other therapies. Should always inform the massage therapist or physical therapist of it's use. I remember when doing my sports medicine fellowship, we used to comment on russian coaches spraying every injury they had with topical anesthetic and i would always laugh at the technique. Now that I am wiser-(herbally), they actually had a great technique overall in attempting to distract the athlete while ultimately stretching injured muscle. Now using it for a fracture .....not!

*Capsicum also comes in oral form....obviously since it is derived from pepper. But I think its best application it topically, as you will read from other posts, I prefer the use of turmeric, white willow bark boswelia for inflammation. In the future I will talk about arnica and tea tree oil.





(Altman RD et al, Semin Arthritis Rhean 1994, 23:25-33).

(Watson CPN et al Clin Ther 1993, 15:510-526)

(Diabetes Study Group, Diabetes Care 1992, 15: 159-165).

glucosamine sulfate

When I finished my sports medicine fellowship at DePaul University, I was doing the usual family practice thing in the office but then applying physical medicine to all patients. I was seeing a large number of knee pains especially during spring and summer. Many consults were from my partners and at that time they had a large number of older patients. With the multitude of medicines they were on already, I dedided to try something I read about in a journal. At the time glucosamine sulfate was just gaining momentum in the US. All the studies available were from Europe comparing glucosamine sulfate to naprosyn and ibuprofen in joint range of motion. Of course the results were equal if not better than the two medicines. With the lack of gastrointestinal side effects. I began asking patients to try 1500 mg daily of the supplement but there was no place to buy it aside from walgreens. Nothing against that chain (thats when they didnt have drive through) but I found only a small group had nice results. Usually it was the patient that went a step further and found a distributor that marketed their own brand. So quality was proving a better impact with knee pain patients that the quanitity driven chain stores.

Glucosamine sulfate studies were usually with chondroitin sulfate. The action was thought to be stimulation of that little cell called a chondroblast. These are the ones that build up the cartilage matrix when damage has occurred to the smooth moving surface of a joint. There were later studies in the US, a big one was teh GAIT study which said it didnt help compared to celebrex. Problem is that the study doesnt specify if the glucosamine was pharaceutical grade or off the "walgreens shelf" brand. They also only used glucosamine not g-sulfate or g-HCL. Well, my patients respond and no side effects to stomach ulcers, renal failure or heart disease like they do with celebrex.

The "Saguil Approach"= remember, glucosamine is a means to get to an end. I always combine it's use with a proper diet, an antiinflammatory diet and visits with a good physical therapist (that knows McConnell Taping-I believe she is an Austrailian therapist). One the patient and therapist develop better flexibility and Quad control and fix the "Q-angle" of the knee, should be able to decrease the supplement. Omega 3 fish oil is good as well as turmeric, ginger, boswelia, white willow bark (see previous posts) and cryotherapy.

Turmeric for sore muscles and joints

The active ingredient from the plant is curcumin. Many studies have been started on the healing properties of curcumin. It is thought to work as a cox2 inhibitor. Sooner or late, we will hopefully see the documented positive results on paper. A few good supplement companies produce combination supplements for inflammation which include the herb. If suffering from inflammation and muscle soreness, consider a few of brands mentioned below. The positive result is that turmeric is also used in certain cultures for healing stomach ulcer. The typical prescription for swelling and inflammation is an NSAID (nonsteroidal antiinflammatory drug). Motrin, ibuprofen, advil are one form of the family of nsaids. Motrin at high dose works well for pain, swelling and even fever. A common side effect is an upset stomach due to its side effect of decreasing the protective layer of mucous that lines the stomach. The family also flares up ulcerative colitis when used. Thus the beauty of turmeric in being able to help with pain from a muscle strain, broken bones, joint swelling without causing ulcers. The national institute of health states that some studies indicate liver problems so until studies are completed, people with gallbladder disease should be careful in using this supplements. Turmeric is used in many Indian foods and give the yellow coloring to many dishes. Ayurvedic medicine practitioners rely heavily on the powder form for many ailments including cancer treatment.

An easy to attain form of tumeric is from New Chapter....Zyflamend. Only problem I found is it has a good smell of oregano. Pill can melt if held in the hand for long time. Works great for acute muscle damage or inflammation. On going studies also show great results withmen who have prostate inflammation. 6 months of use actually reversed several cases of in situ precancers for greater than 50 percent of the med who were being followed. See their website. http://newchapter.com/

I use IF relief from Natures Sunshine. It may be harder to find but I order it from an herbal store I used to go to in Clermont Florida and they usually give my patients a discount.

http://www.herbpantry.com

chiropractors

Are Chiropractors safe? Most people wit back pain will come to the office or Express Care with an acute event. Many will either have used a Chiro in the past or were considering one before seeing me. On the whole, I like chiropractors. I think the theory of subluxation is valid and many patients of mine have had good results with visiting a chiropractic practitioner. To argue a fact, I have had some horror stories from Neurosurgery friends stating bad results from manipulation. (Remember, this is also true of seeing a doctor for a diagnosis, occasionally there are some docs who just don't practice good medicine). To be safe, get a recommendation from a friend or doctor who has used the chiropractor before. See a primary care doctor or an orthopedic surgeon also to make sure you have two opinions. Remember, if it continues to hurt when you have had the manipulation, medicine, therapy or needles.....something is wrong. It never hurts to do and xray for trauma or and mri for anatomy but the history and physical exam is always the strongest thing in a doctors arsenal to defeat pain and disablility. A doc that goes straight to mri in treating back pain is missing something. (3 in 10 people with no pain will show a bulging disc on mri).
One thing I have to say is I have seen the growing trend for chiros to have physical therapists in the same building or do the therapy on their own. I am very particular about what a therapist does to my patients. I often ask someone with an acute flare up if they had attempted physical therapy in hopes that we can get them to see someone but I immediately get the answer,"I tried therapy and it doesn't work". When patients see me for back pain, if there is no nerve death yet and work is tolerable, maximize on every possible modality, treatment and herb/pill to get the pain away. It only goes away with changing muscle tone, letting the disc go back in, continuing with proper nutrition and sleep. For the person that can't afford therapy, time off from work or medicine, time to save money and change jobs.
Miracles don't happen when you come to the er, chiro or MD. If back pain is from chronic weight, manual labor or poor nutrition and poor healing, most docs can only help to keep the pain to a minimum while the patient changes the lifestyle. Had a guy come to the ER yesterday who had back pain and a few bulging discs since last year but can't afford PT and can't take time off work. He wanted narcotics cause they help with pain. He has been suffering since last spring and hasn't done anything but visit the Er every once and a while. I was going to give him pills but I would only be postponing his need to make a lifestyle change. Wife already stated he had an addiction problem to vicodin so obviously he wants a shortcut and will not address the big issue of finding another job or getting a loan to see a good physical therapist. Said he tried chiro and PT and it "didn't help"...(obviously he only tried one center).
Do the research on the chiro, see a physician also and make a timetable to change your life. The back is telling you something isn't working with life now so you must make a change.