Friday, July 31, 2009

Cycling and Knee pain

The knee is one of the most common sites for injuries among cyclists. When you consider the number of revolutions our legs make on the bike, it's no wonder we have so many issues with knee pain as cyclist. The knee is a complex biomechanical piece of machinery and when structures are not functioning properly, it will let you know with a nice dose of pain. There are many conditions as well as outside factors that can affect the knee. I see many common knee injuries that come about from cycling such as patellar tendonitis, ITB syndrome, Pes anserine bursitis, chondromalacia patella, as well as plica syndrome, among others. On some occasions I have seen patients that have been to every health care provider possible with no resolution of their symptoms. They have had X-rays and MRI's, as well as bike fittings by experts. Some even had C.T. scans performed to determine and correct leg lengths which were then corrected and the knee pain persisted. In many of these cases, I tend to find a combination of myofascial problems and mechanical joint problems or problems with the muscles and fascia independently. These will not show up on any X-rays or MRIs. In fact, many of the previous knee injuries mentioned also contain myofascial problems that need to be addressed along with the main injury. Here is a case study to help give you some insight into this particular problem.

A patient presents to my office with bilateral knee pain that is present after riding his road bike. Review of his past medical history is non contributory and family history is benign as it relates to his present condition. He reports that he has also seen two other physicians and gives me their reports as well as the knee MRI's and X-rays that were taken. All results were negative and both physicians diagnosed his condition as bilateral knee sprains with no specific areas noted. They recommended that he rest off his bike. After finish
ing his history I proceed to examine him and his physical exam was normal as well as his vital signs. He is in his 20's, physically fit and has been riding for several years. He has recently started training at a higher intensity as well as spending a longer amount of time in the saddle. Range of motion is full in all planes. His arches and gait are normal as well. No excessive rotation is noted in his hip or knee. Leg length was assessed and there are no structural or functional changes noted. I performed several orthopedic tests to his back, hip, knee and ankles with no positive findings. I begin to palpate (touch) his knee and surrounding muscles. When I get to a muscle called the vastus medialis and find several knots called trigger points, the patient says "that's it doc, that's tender" I continue to feel around his knee and find that the quadriceps muscles are very tight overall and contain several more trigger points. Now I ask the patient if the pain that occurs when I press those spots is reproducing the knee pain he gets and he responds “yes that’s it”. If you take a look at fig. 1, I have placed an x and then some small dots so you can see the pattern of referral from the tender points

Next, I take a look at his cleats, bike fit and talk to him about who positioned him on the bike. The name is familiar to me and he has not made andy changes since then. One thing he does note to me is that he has been adding miles over the past few months as well as intensity. At this point, it is likely that his knee pain was associated only with muscle and joint tissue dysfunction. In this is the best case scenario for this patient because with the right treatment, home stretches, as well as self massage, the problem could be fixed. When I talked to him about recovery he admits to me that he doesn't do very much other then eating after he works out and adding some light days. In my opinion, he is missing half of the full picture. Your body builds and adapts between training sessions and during that period is where my interest lies because we have really only scratched the surface of what is occurring on many different levels. Needless to say you need more than good nutrition and hydration. If you look at my flow chart for recovery fig. 2 you will see the six pillars of recovery that your training rests on. If one pillar is missing things will fall apart with your training and/or your body. In this case, he missed on many points and he did not give himself time to recover so his muscles and tissues could adapt to the increased in demanded he placed on it.

For the purpose of this article we will focus on the physical pillar of recovery and what I did as it relates to this injury. I began using electric stimulation and heat to the area and began a manual technique of working out the tight muscle tissue and trigger points in an effort to decrease the tight tissue and increase normal range of motion. I also manipulate or adjust the joints of the foot, knee, hip and low back to restore those normal motion patterns. In addition, I recommend some specific stretches, as well as the use of a Quadballer one of several great tools by trigger point therapy for the patient to use at home as part of his recovery routine. If you look at fig 3, you see an example of a patient using the Quadballer in an effort help maintain the benefits from the care he is given in my office. He responds well to care and is soon riding pain free at a 3 month follow up. . There are many ways to treat knee problems make sure you find the right provider for you so you can fix the problem and not the symptom. Most of all, don't forget the other half of your training recovery! Otherwise you will soon find that pain raising its ugly head.

Wednesday, July 29, 2009

Exercise and High Intake of Omega-3 Fatty Acids

"Exercise and High Intake of Omega-3 Fatty Acids May Lower CVD Risk in Overweight Young Adults"

Keywords:CARDIOVASCULAR DISEASE, OVERWEIGHT, OBESE - Omega-3 Fatty Acid Index, DHA, Cholesterol, LDL, HDL
Reference:'Cardiovascular risk factors in young, overweight, and obese European adults and associations with physical activity and omega-3 index,' Ramel A, Pumberger C, et al, Nutr Res, 2009; 29(5): 305-12. (Address: Unit for Nutrition Research, Landspitali University Hospital, University of Iceland, Reykjavik IS-101, Iceland. E-mail: ).


In a cross-sectional study involving 324 subjects (20-40 years of age, BMI: 27.5-32.5 kg/m(2)), excess body fat was found to be the most important variable associated with increased risk of CVD in young overweight and obese adults, compared to physical activity and omega-3 index. In the study population as a whole, 41% were found to have increases in blood lipids, 32% were found to have elevated blood pressure, and 12% were found to have disturbed glucose metabolism. BMI was found to be significantly associated with increases in most CVD risk factors, excepting cholesterol levels (total, LDL, and HDL). Subjects who were the most physically active (highest quartile) were found to have lower fat mass, leptin, and interleukin-6, and higher HDL cholesterol. Levels of DHA (docosahexaenoic acid) in erythrocyte membrane were associated with lower LDL cholesterol. The omega-3 index was not associated with lower LDL cholesterol. These results suggest that, 'body fatness remains the most important variable associated with increased CVD risk factors in young overweight and obese adults,' however, physical activity and DHA status may help to reduce risk."

Saturday, July 25, 2009

Blake Griffin Shoulder Injury

During the 3rd game of the NBA Summer League, the Clippers recent #1 pick, Blake Griffin, suffered a right shoulder injury. Even with the injury, Griffin was able to finish out the rest of the 5 game league averaging 19.2 points and 10.8 rebounds.

Griffin was evaluated by team doctors and was diagnosed with a Right Shoulder Strain. Strains are usually an injury that is an easy fix, given the athlete is allowed enough time to rest. Here is a quck description:

Strains and Sprains
Although bones can sometimes be fractured with acute sports injuries, the most commonly injured structures are the muscles, tendons, and ligaments. Tendons attach muscles to bones, and ligaments attach one bone to another.

An acute twisting or overextension of a joint can lead to tears of muscles and tendons, called “strains,” and tears of ligaments result in “sprains.” These tears range from mild to severe. In mild injuries, just a few fibers are torn or stretched. Severe injuries, where there is a tear through the full thickness of the structure, are most often considered unstable injuries and frequently require surgical intervention

As I type this I'm reading articles/blogs mentioning "Surgery," "Clippers Curse," "Injury Plagued Season," etc... If you don't remember, Griffin has quickly and efficiently overcome a previous knee injury, concussion, and also managed to not be phased by
this wrestling maneuver performed by Ameer Ali in last years NCAA tournament.

The only concern I have with Griffin's injury is the pressure for him to return quickly. Let the man rest, get treatment, and recover for the appropriate 3-4 weeks. This should have no effect on his upcoming season, and I look forward to watching him have a successful season with the Clips!

*And No, I will never post a picture of Griffin playing against my beloved Syracuse Orange from this past years NCAA Tourney. Go Cuse!

Friday, July 24, 2009

Cycling and Saddle Sores

For many recreational cyclists, the worst part about getting back on a bike is the inevitable saddle soreness. Depending on how long you've been away, it may only take a few minutes before pain in the rear starts taking the joy out of your ride. Fortunately, it will get better with time. The more you ride, regardless of physical exertion, the longer you'll be able to sit as your tissues adapt to the added stress.

A Short Order

One way to reduce saddle soreness is by wearing cycling shorts. You will notice a huge difference when you stop using shorts over cotton underwear. Cotton absorbs and holds sweat, leading to a very chafed bottom.

I recommend using bib-shorts. This style, which has built-in suspenders, usually fits better than traditional shorts and does not shift while riding. When the chamois moves, it causes friction. Friction can cause irritation, chafing and eventually saddle sores.

It's important to clean yourself right after a ride so organisms don't start to grow and multiply. Make sure your bottom and crotch are as clean as possible before a ride to help prevent organisms from growing in the first place. For long-distance rides, cyclists might consider changing shorts at various points to help cut down on possible infections and chaffing.

It's important to remember that when you stop riding your sweat starts to dry. Because it contains salt, sweat will turn into solid crystals that start to sand the skin. The longer you're on the bike, the more you will need to apply chamois crème. Reapply when you stop to help decrease friction and keep a barrier from the potential salt crystals. Most crèmes on the market work pretty well, but try a few and see what works best for you. I do not recommend Vaseline. It is hard to get out of clothes, clogs pores, and stays on the hands, which can get into your gloves and cause a big mess.

The Right Saddle for Your Ride

Research has shown that traditional saddles compress various nerves and blood vessels. Over the past few years, saddle manufactures have been trying to decrease the pressure to these areas, and many companies now sell saddles with an open channel down the center.

Riders should also pay attention to saddle size and cushioning. There is a reason other than weight that you don't see huge saddles on the pro tour. Having a large area of contact with the bike increases the potential for pressure, which in turn causes nerve and blood-vessel issues. You want your sit bones and some buttock tissue to receive most of the pressure from the seat, not the area were most of the blood vessels and nerves connected to your genitals are located. Some companies, such as MoonSaddle, have taken this idea to the next level when designing seats.

Serious amateur riders and enthusiasts who spend long hours on their bikes need a comfortable, light saddle that eliminates all numbness. This cuts down the risk of damage due to repetitive micro-trauma.

I sometimes hear or read advice telling people to lower the tip of their saddle. This may help, but it creates an entirely different health issue. This adjustment changes the biomechanics of the bike. Riders can develop knee pain or other issues, which often leads to more bike adjustments and so on and so forth. The end result is an ill-fitting bike that causes more harm than good. The saddle should remain level, allowing the rider to slide a bit back on long climbs and allow the body to utilize fresh muscle fibers.

So what saddles are best for you? Experiment before choosing one. See if you can get a loaner saddle from your local bike shop. I use two different versions of the Selle SMP, a minimalist Stratos for my racing bike and a Glider, which has a bit more padding and is wider, for my touring bike. This saddle has a huge gap in the middle of the seat as well as a curved overall shape to help eliminate the pressure of the nerves and blood vessels. Its front is bent forward for added control when climbing or descending. In addition, the back portion of the saddle has a drop-out to prevent the tailbone from hitting the seat on uneven surfaces or hard bumps.

I just finished the 1200-kilometer Paris-Brest-Paris ride without any numbness whatsoever. Selle Italia also makes a few models I think are good alternatives for riders that experience numbness. In addition, Specialized has a broad range of sizes and gender-specific saddles developed by Dr. Andy Pruitt, one of the most knowledgeable professionals in cycling on body position and injury.

The best way to deal with chafing and saddle sores is to treat your bottom like a baby's. Use Destin, Balmex or any ointment with zinc oxide. In addition, using triple antibiotic plus a pain reliever on long rides is helpful. Remember, be picky when choosing your saddles, shorts, and creams; keep that area clean and you will find your rides to be much less of a pain in the butt.

Thursday, July 23, 2009

Supplementation With Nattokinase May Decrease Plasma Levels of Fibrinogen, Factor VII and Factor VIII

Keywords: CARDIOVASCULAR DISEASE - Nattokinase, Fibrinogen, Factor VII, Factor VIII
Reference: "Nattokinase decreases plasma levels of fibrinogen, factor VII, and factor VIII in human subjects," Hsia CH, Yang NC, et al, Nutr Res, 2009; 29(3): 190-6. (Address: Division of Cardiovascular Medicine, Changhua Christian Hospital, Changhua 500, Taiwan).
Summary: In a study involving 45 participants (healthy volunteers, patients with cardiovascular risk factors, and patients undergoing dialysis), results indicate that supplementation with nattokinase may decrease plasma levels of fibrinogen, factor VII, and factor VIII. The subjects received 2 capsules of nattokinase per day (2000 fibrinolysis units per capsule) for a period of 2 months. At intervention end, plasma levels of fibrinogen, factor VII and factor VIII decreased similarly in all subjects (fibrinogen 7-10%, factor VII 7-14%, factor VIII 17-19%). Thus the authors conclude, "In summary, this study showed that oral administration of nattokinase could be considered as a CVD nutraceutical by decreasing plasma levels of fibrinogen, factor VII, and factor VIII."

Monday, July 20, 2009

Plant Sterols and Cholesterol: Divide the dose?

Plant Sterols: Multiple Divided Doses More Effective at Reducing Cholesterol than a Single Large Dose



"Plant sterol consumption frequency affects plasma lipid levels and cholesterol kinetics in humans," AbuMweis SS, Vanstone CA, et al, Eur J Clin Nutr, 2009; 63(6): 747-55. (Address: PJH Jones, Richardson Centre for Functional Foods and Nutraceuticals, University of Manitoba, 196 Innovation Drive, Smartpark, Winnipeg, Manitoba R3T 6C5, Canada. E-mail: ).
In a randomized, placebo-controlled, 3-phase (6 days/phase), crossover, supervised feeding trial involving 19 subjects, consumption of plant sterols given in smaller doses 3 times per day was found to be more effective at reducing cholesterol than a single large dose. Subjects participated in 3 phases: 1) control margarine with each meal; 2) 1.8 g/d plant sterols in margarine with breakfast, control margarine with lunch and dinner; 3) 1.8 g/d plant sterols divided into thirds and consumed with breakfast, lunch, and dinner. Results found a reduction in LDL cholesterol (0.21 mmol/l lower) and the highest cholesterol fractional synthesis after the small frequent dose phase. As compared to the control group, cholesterol absorption efficiency decreased by 36% in the small frequent dose phase and by 39% after the single larger dose phase. The authors conclude, "Present data indicate that to obtain optimal cholesterol-lowering impact, plant sterols should be consumed as smaller doses given more often, rather than one large dose."

Sunday, July 19, 2009

Bradley Wiggins in the Tour De France

OMG Bradley Wiggins is doing well in the Tour ohhhh he must be doping right?


Lets take a look at Bradley Wiggins who has a long history of winning on the track.

Olympic Games2000 Summer Olympics
Bronze, Team Pursuit
2004 Summer Olympics
Gold, 4km Individual Pursuit
Silver, Team Pursuit
Bronze, Madison
2008 Summer Olympics
Gold, 4km Individual Pursuit
Gold, Team Pursuit

World Championships

1998 UCI U19 Track World Championships
Gold, 2km Individual Pursuit
2000 UCI Track World Championships
Silver, Team Pursuit
2001 UCI Track World Championships
Silver, Team Pursuit
2002 UCI Track World Championships
Bronze, Team Pursuit
2003 UCI Track World Championships
Gold, 4km Individual Pursuit
Silver, Team Pursuit
2007 UCI Track World Championships
Gold, 4km Individual Pursuit
Gold, Team Pursuit
2008 UCI Track Cycling World Championships
Gold, 4km Individual Pursuit
Gold, Team Pursuit (World Record Time)
Gold, Men's Madison

World records

4000m Team Pursuit, 3:55:202, (as part of Great British team), Beijing China, 2008
4000m Team Pursuit, 3:53:314, (as part of Great British team), Beijing China, 2008

Professional victories
Stage 1 ITT, Tour de l'Avenir
Six Days of Ghent
Stage 2 ITT, Circuit de Lorraine
Stage 8, Tour de l'Avenir
Prologue, Critérium du Dauphiné Libéré
Stage 1 ITT, Four Days of Dunkirk
Stage 4 ITT, Tour du Poitou-Charentes et de la Vienne
Stage 6 Combativity award, Tour de France
Duo Normand (with Michiel Elijzen)
Stage 1 TTT, Tour of Qatar
Stage 3b ITT, Driedaagse De Panne-Koksijde
Beaumont Trophy

Not sure if that's enough to covince everyone that he has a strong motor, world class I say. Big deal if the guy loses some weight and has a motor that doesn't make a podium finisher. (they said that about Lance as well) First off the guy lost 6kg's that's 13 lbs over the course of the year that is like taking away the weight of a Bike! That means that he went from a 6' 3'' 160lb guy to a 6'3'' 147lb guy and was able to retain that power. (Lets remember he was not a sprinter but a pursuiter big difference). Think about what that does to your power to weight ratio. The rule for climbing prowess: You should weigh (in pounds) no more than twice your height in inches. So at 6 feet 3 (75 inches) you'd need to weigh 150 pounds rather than 160 pounds. So at 147 I think he can stay with the best climbers maybe not the attacks of Alberto Cantador but he can hang with the best of them as was evident today. Sure Doc you have it all figured out give me an example besides Lance. Ok, Five-time Tour winner Miguel Indurain is 6-foot-2 and weighed 190 pounds when he began racing. Lots of miles reduced him to 175. At that weight, his huge power output enabled him to ride with the specialist climbers in the mountains even though he outweighed most of them by 30-40 pounds. And of course he was nearly unbeatable in flat time trials where weight doesn't matter much but power output does. It is commonly written that to win the Tour de France you need to be able to hold 5.9 to 6.0 watts per kg for 30 to 45 minutes at a time, 3 to 4 times over the course of a 5 to 6 hour day in the mountains. So for a podium spot if we are looking at numbers I would say 5 to 5.5 and I am sure Bradley is in that range.

Lastly the physcological aspects of sport are the always the X variable and this guys already knows how to get himself into that zone to win, mask pain, etc etc. If you listen to him in interviews or read his tweets you know this guy is mentally preparing. It is something that he has always done for the track but now its the tour. So what do I think? I think he could defiantly find himself on the podium but only time will tell and a few mountains.

Friday, July 17, 2009

Yao Ming Out for Season

It is likely that the Rocket's Center, Yao Ming is out for the 2009-2010 season. Yao has recently elected to undergo surgery to fix a hairline fracture sustained in his left foot during the Western Conference Semi Finals against the Los Angeles Lakers.

Yao is going to have a series of surgeries to hopefully repair and prevent further injury. First a bone graft will be done to repair the hairline fracture. A bone graft is a surgical procedure that replaces missing bone with material from the patient's own body, an artificial, synthetic, or natural substitute. Bone grafting is used to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly (Wikipedia). Second, an additional surgery will be done to lower the arch of the foot, which will alter the biomechanics of the foot all together, and hopefully prevent further injury.

The good news is, Cleveland Center Zydrunas Ilgauskas underwent similar surgeries in the past, and has seemingly had an unaffected career thereafter.

Levi Leipheimer Wrist Fracture

Levi Leipheimer has fractured his Wrist during a crash at the Tour de France yesterday and as I write this is most likely in the recovery room. For those of you interested into what happened it looks like he must have fallen on an out stretched hand that placed all of the pressure on the Scaphoid bone a small bone in the wrist. So big deal right just tape him up and he can muscle around it. No Way!!!

He has a transverse
fracture of the scaphoid bone that can be much more of a problem and if the fracture of the scaphoid was more proximal or closer to his wrist then he is much more likely to have major complications like avascular necrosis, nonunion or radiocarpal degenerative arthritis. You see in the middle of this bone is the main supplying arte

ry so if the fracture occurs below this then you will have no blood supply so the best approach is to place a small titanium screw to fuse the two bones so there is less likely for a problem to occur. With Avascular Necrosis the position of the fracture relative to the principle artery is the most crucial factor so I hope that it is a more favorable spot. If the fracture site is Distal or more away from the wrist then it is unlikely to occur. Another complication is Nonunion and occurs in approximately 30 percent of fractures involving the waist of the fractures and that is another reason why his was fused. Take a look at the 22mm screw that was place in his scaphoid on the right.

This was taken from Levi's tweet's that are great by the way so make sure you add him. The Radiocarpal Degenerative Arthritis may follow a healed scaphoid fracture of any type but he will be retired by then. Healing time 6 to 20 weeks is the text book answer but Levi is a professional athlete so the healing time should be much shorter. The athlete's I have treated with this condition we have also added Micro current to speed healing time as well as Low level laser this combined with great nutrition and a change in his supplements and the quick surgery should serve him well.

One final note I hate to see athlete's get injured when they look like they are doing so well in an event and in my opinion Levi had a great shot at the podium. He will be missed by Lance and Alberto on team Astana that's for sure. So I wish him a speedy recovery. Also check out Levi's site for more Info.

Tuesday, July 14, 2009

Golf : Improve your Swing



How to Fix Them?


Guest Article today on Golf swing mechanics from an old classmate of mine Dr. Don Wallace who used strong scientific data and rehab principles to correct some golf swings. Check it out!

Frustrated with your inconsistency. Have you tried all latest clubs? Maybe it’s not your clubs. Is it possible that your body is unable to perform a proper golf swing? Strength, flexibility, coordination and balance will help golfers play to their optimum potential.

Vladimir Janda was a renowned Neurologist and physical therapist who determined that there are certain muscles in our body are prone to be weak and certain

muscles that are prone to be tight. Interesting enough, the muscles that tend to be weak are the same muscles necessary for in an elite golf swing. These weak or inhibited muscles need to be activated and strengthened enabling you to perform a proper golf swing. The golf muscles that tend to be weak are the internal and external obliques (abdominals) the glut max and medius, (hip/buttox) and lumbosacral (lower back) muscles. The muscles that tend be tight are adductors (inner thigh), Psoas (Hip flexors), hamstring and thoracolumbar (mid to lower back muscles). An important finding by Dr. Janda is that the tig

ht muscles cause their opposite muscles to be weak or inhibited by something called reciprocal inhibition. For example if you perform a curl contracting your bicep, your tricep will be relaxed. So to get you optimum results, prior to strengthening your weak muscles, you should stretch your tight muscles.

A study of 750 golfers by David Leadbetter revealed that the elite golfer transfers 90% of their body weight to the back leg during the backswing while the amateur

s only transferred only 50%. On the initiation of the downswing a force of 110% of their body weight was transferred to the front leg of the elite golfers. The amateurs only transferred 65%. One reason that this occurs is because the body is unable handle these loads. It is important to recognize the swing fault, but if we know why it occurs we can fix the problem.

Lets go over some of the swing faults and what is causing them.

1) Reverse Pivot (figs B,L)

The reverse pivot is when the golfer’s back leg is straight and the body weight is shifted to the front leg. This reverse weight shift occurs due to compensation caused by weakness of the back leg’s hip, thigh muscles, specifically the glut max and the quadriceps muscles. If our back leg cannot handle 90% of our body weight during the back swing, the golfer will tend to straighten the back leg by locking the knee which helps support the body weight and then the golfer will tend to shift the weight to our front leg to maintain balance.

2) Inability transferring their body weight to the front leg

a) At the initiation of the downswing

b) At ball contact (fig F)

c) At the follow through (fig O)

This occurs due to lack of strength in front leg gluts and thigh muscles, not having the proper balance or a delay in firing of these muscles. As a result, we compensate by transferring the body weight on our back leg, something that you will never observe from an elite golfer. This will cause to hit the ball thin and again a loss of distance.

3) Swaying of the Pelvis

a) During the back swing (fig C)

b) During the downswing (fig G)

This is caused directly to the weakness or inhibition of the glut medius muscle. This muscle has a force of twice our body weight when we stand on one leg. So if the glut medius is weak or there is a delay in contraction of this muscle, the pelvis will sway in the direction of the loading. There is a tremendous amount of stored energy lost if this occurs.

4) Entire body (hips, torso, head and shoulders) sliding forward during the down swing (fig H). This results in a loss of distance and typically a push or slice. Again this is due to the weakness of the glut medius.

5) Swinging too much with our arms with limited body rotation (figs D, P)

One reason for this is inhibition of our internal external oblique muscles. A typical person does not rotate their upper body during the day. These muscles tend to go to sleep or become inhibited. Another reason can be lack of flexibility and mobility of the upper back. If there is too much curve in the upper back and there is overall poor posture of the spine where there the neck, mid and lower back are not aligned torso rotation will be limited.

Most of the rotation of our torso and shoulders come from the rotation from our mid back, not our lower back.

6) Loss of Spine angle

a) During the back swing (fig K)

b) At ball contact (fig M)

The reason for this is multifactoral

a) When the lower back muscles are too weak, they will not be able to hold their torso steady during the swing.

b) During the back swing as we discussed before if the golfers’ obliques are inhibited or weak, and the thoracic spine does not have proper flexibility or even improper posture, causes inadequate torso rotation. The result is a tendency to compensate by lifting their torso (body/head) up to try to create subconsciously yet ineffectively, a further backswing.

7) Coming over the top (fig J)

There are a number of reasons for this, but one of the primary reason are the arms and hands getting ahead of the body rotation.

When performing strengthening exercises I recommend to perform functional exercises, these are exercises that correlate to everyday life and/or your sport. For instance, sitting down pressing weight from a chair is a nonfunctional unless your job is to be a human automobile jack to press up cars with your legs so people can change their tires. An example of a functional exercise is performing a lunge. When performing a lunge, we are strengthening the gluts, quads while maintaining our core and balance. This is considered a functional exercise because when we walk, run, get up from the seated position or go up and down stairs we are using all of these muscles. Strength with coordination and proper sequence of firing of the muscles with balance is what is necessary in an effective golf swing. Strength without these other essential components is useless.

An efficient yet effective way to improve balance and actually glut medius strength, is to perform as many exercises that you do at the gym on one leg. For instance, if you sit and perform a curl you are doing very little for anything except your bicep. On the other hand, standing on one foot the glut medius and balance will be challenged while doing the curl curl.

Correcting the above swing faults will have common exercises.

If any of these exercise become too easy than advance to performing these exercises on a wobble board or physio-ball. This will really challenge your core, gluts and balance. Matter of fact, a study was performed and indicated that there was 300% more activity of the core muscle when doing the exercises like bridging on an exercise ball.

Correcting the 7 Swing Faults

Lets look at the reverse pivot and the non-transferring of the body weight to the front leg on the initiation of the down swing and the follow through. The first thing that you want to do is to stretch the hip flexors and hamstrings if they appear to be tight. The next thing is to strengthen and facilitate the glut max and the quadriceps while increasing balance. Two ways to check for weakness of the quads and glut max is to observe two movement patterns. One should be able to rise from the seated position with one leg smoothly and relatively easily and secondly is to observe the squat, the golfer should be able to squat down fully with the heels on the ground and the torso only flexing forward slightly.

Some great exercises are lunges, step ups, squats, and 1 legged bridges with a dip. When performing the lunges progress by lifting the stabilizing foot off the floor so all of your weight is on one leg. When these exercises get too easy, add more weight and or do them on a wobble board or physio-ball to make them more challenging. This will significantly help with balance and core strengthening.

The swaying of the pelvis back and forward or the entire body sliding forward can be corrected from stretching the hip adductor (inner thigh)muscles, strengthening the glut medius and improving balance.

Some of the exercises to strengthen the glut medius are: one legged bridging, one legged lunges or one legged step ups, side stepping with a elastic exercise tubing tide around the thighs, lying on your side with your elbow on the floor and your legs straight and lift you pelvis off and of course adding balance boards and physio balls to the exercises is added challenge.

Limited Body Rotation can be help by having good posture. Notice all of the pros have excellent posture. If you look at most pros from the side as you are looking at their target you will see that their head, neck, upper and lower back are aligned. Of course increasing flexibility of the upper and mid back (thoracic spine) is essential since it is the area of the spine that rotates the most. An exercise to help with torso flexibility is lying on your back and rotating hips and knees side to side. Another is sitting on the floor with one leg bent crossing over the other leg that remains on the floor and placing the opposite elbow on it and rotating as much as possible toward the flexed knee. I recommend checking out the exercises and stretches by Peter Egoscue.

The next thing is to strengthen the obliques. This accomplished by using a cable column or elastic exercise tubing, hold onto the handle with both hands and rotate to the back swing about ten times and turn around and rotate to the down swing. Again if you want to challenge yourself more, stand only on your back leg and rotate to the top swing ten times and then turn around and rotate to the top of your down swing standing only on the front foot. This will not only strengthen your obliques it will help with balance increase the strength and stabilization of the gluts and quads. So if you only want to do one exercise I recommend this one, it facilitates all the muscles used in the golf swing and will improving your balance.

Loss of spine angle again can be helped by improving the body rotation performing the exercises above but also by strengthening the lower back muscles. Proper dead lifts, lumbar extension exercises are very helpful. If your lower back is not ready for lumbar extension exercises, try the reverse lumbar extension exercises. You need a high table, lying face down with your thighs hanging off the table and lift them parallel to the floor. Bring the legs and thighs back down to the floor and lift them back to parallel about 10-15 times.

Coming over the top

There are a number of reasons for this, but the primary reason is the arms and hands getting ahead of the body rotation. So if we dominate our swing with rotation of the torso allowing centripetal force to be created and transferred to the arms and club rather than swinging with predominately the arms, the shoulders and club are more likely to stay on plane. Therefore the exercises for rotation will help the over the top swing. If the upper trapezius muscles are tight and the shoulders are raised up, forward and tense, an over the top swing will be inevitable. Therefore to eliminate this, stretching the upper trapezius muscles and ensuring that are shoulders are back and down will cause the upper trap to be relaxed at address and help eliminate the over the top swing.

Two of the best exercises that are fun and will develop your thighs, gluts, stabilize your lower back muscles and improve your balance are ice skating and rollerblading. If you don’t believe me, observe the development of Olympic speed skaters’ thigh and gluteal muscles.

Performing these exercises described alone is not the only answer, taking lessons from a PGA teaching professional after you get your golf muscles in shape will enable you to reach your optimal golf potential. You also might want to take some videos of yourself and determine if you can identify any of the above 7 swing faults. Now you will have an idea on how to correct them. You can teach a baby all you want to walk but if their body is not ready it will be impossible for them to walk. The instructor can tell you all things that you should do in your swing but if your body is unable to do it, than you and your instructor will be very frustrated.

Dr. Don Wallace

Check out Dr Wallace Website for information on Green Stick and how it can be used to correct and rehab swing mechanics.

Monday, July 13, 2009

Recovery Nutrition: Prescribed Calcium and Vitamin D Post-Hip Fracture Linked to Reduced Mortality

Prescribed Calcium and Vitamin D Post-Hip Fracture Linked to Reduced Mortality

In a study involving 221 elderly hip fracture patients, post-fracture use of prescribed calcium plus supplementation with vitamin D was found to be associated with reduced mortality. In women, concomitant use of anti-osteoporotic drugs was also associated with reduced mortality. The authors point out that, "Several studies have shown excess mortality among hip fracture patients compared with the normal population of the same age." Questionnaires were sent to all patients who were still alive (n=137) 27.5 months after the fracture. Four years survival data for all patients in the study population was obtained. Results showed supplementation with prescribed calcium and vitamin D was associated with a 43% reduction in deaths in male subjects and a 36% reduction in deaths in female subjects. Female subjects who also used anti-osteoporotic drugs were found to have an even greater reduction in deaths (43%). Male and female subjects who did not use prescribed calcium and vitamin D or anti-osteoporotic drugs were found to have the highest mortality rate. The authors conclude, "�further investigations are needed to understand the reason for the reduction in the risk of death. Population-based, randomized, placebo-controlled trials with total mortality as the main endpoint should be conducted to verify our results."

"Post-Fracture Prescribed Calcium and Vitamin D Supplements Alone or, in Females, with Concomitant Anti-Osteoporotic Drugs is Associated with Lower Mortality in Elderly Hip Fracture Patients: A Prospective Analysis," Nurmi-Luthje I, Luthje P, et al, Drugs Aging, 2009; 26(5): 409-21. (Address: Department of Public Health, University of Helsinki, Helsinki, Finland).

Tuesday, July 7, 2009

Cycling and Leg Pain

Cycling Medicine: Acute Overuse of the Legs

In the rush to cram cycling into our busy lifestyles, recovery is typically the first thing that gets thrown out the window. After all, it’s easy to prescribe training programs but more difficult to prescribe, or adhere to, recovery programs. Dr. Rick Rosa returns with a cautionary tale about what happens when we push our bodies too far by trying to do it all… By Rick Rosa, D.C.,D.A.A.P.M.

Bike-Run Transition
This year for my birthday, my good friend Dave and I rode 100 miles with over 8,000 feet of climbing. It was a hard ride but I had fun. Once the ride was over I went home to recover while Dave figured he would play a little coed soccer with his wife. I’m not sure if it was the lactic acid bath during the ride or the pressure to do things with his wife that clouded his otherwise rock solid judgment, but he set himself up for disaster.

While playing soccer he was running up and down the field making quick accelerations and decelerations as well as lateral movements. At one point he felt a sharp pain in his hamstring, namely the semitendinosus muscle. Soon after that, he began to experience pain in the upper part of his rectus femoris muscle (the middle thigh). He eventually came into my office after the injury did not improve and he noted it was affecting his riding.

Dave is a seasoned 16 year Cat-3 cyclist and, like many cyclists, he is always trying to find time to train. He is well versed on most things associated with cycling including injuries, and he did take it easy for a while, limiting the amount of intervals and power level he was producing. The pain was not improving so he finally brought it up in conversation with me, so I scheduled an appointment to see my good friend and help him with this problem.

Case History
In looking at his past medical history, I discovered that he had injured his ACL ligament in his left knee when he was a child playing soccer and started cycling to keep that knee stable and strong. The injury was a mild tear and more of a stretch of the ligament which left him with a bit of extra play in that knee than I would like.

Upon examination of the legs, I noted that he had some limited flexibility in the injured leg in multiple muscles and planes of movement. In other words, he was a bit tight but he had been working on this since the injury, which means he was previously even more limited in movement. Like many cyclists that I had seen, he had limited movement in the hamstrings and some decreased movement in adduction (bringing the leg into the body). In addition, he had pain on the inside or medial side of his hamstrings in the belly of the semitendinosus muscle and the middle of the thigh, or rectisformis muscle, when I palpated them. Lastly his left hip joint was a bit restricted in movement.

Fatigue and Overload
So how and why did this happen? Well in this case, we don’t have a de-conditioned weekend warrior who has an imbalance between quad strength and hamstring strength because those people can have this very same injury just as easily. Was it the old injury to his knee that made him predisposed to this strain in his leg? Maybe to some degree but the real culprit in this case is muscle fatigue.

Think of your muscles as engines, brakes, stability control, and shock absorbers all in one. When the muscles become fatigued from work such as a long hard climb, they are affected at a physiological level. This affects all fiber types such as type I, IIa IIb, IIc, and III, which can damage and deplete the energy stores. You can still turn the engine on and hit the brakes but the stability control systems are not up to par and you have no shock absorbers at all.

In a study done at Duke University (1), they looked at muscle fatigue and susceptibility to strain injury. What they found was that muscles lose 69.2% to 92% of their ability to absorb shock when they are fatigued. We incur injury to our muscles mostly during eccentric contractions; for example, when we plant our foot down when running during a soccer match, or when the body is fatigued and not able to absorb the shock or control the movement as well, leading to injury.

Prevention and Treatment
Well now that we know how, why, and what to do to prevent and treat this injury, we need to know the initial steps to begin the appropriate treatment. Firstly, playing a rigorous and strenuous sport such as soccer after a cycling 100 miles is not conducive to active recovery which your body needs to rest and heal. Secondly, it is just as important to maintain balance and flexibility in order to prevent these types of injuries.

So, how did I treat my good friend Dave?

First, I told him to stop the co-ed soccer for a bit because that eccentric loading is a killer for an injury like this. On the bike, I asked him to keep the watts down as well as the time and put him into an active recovery mode. I reminded him of the importance of sleep and nutrition and gave him a supplement that helps with recovery. Then, I used electric stimulation, ultrasound, cross friction massage, manipulation and topical creams in an effort to heal the tissue, minimize scar tissue formation, and restore proper biomechanics. I also used a special tape called KINESEO tape that helps with support and healing of the injured muscles. Dave was most impressed with the tape.

Dave responded well and was soon kicking my butt in the Assault on Mt. Mitchell, a nice 102 mile ride with over 11,000 feet of climbing in North Carolina, which oddly makes me feel great!

One important last note, it is important not to rush your way back after large and small injuries because cycling biomechanics can get thrown off very easily. After injury, cycling biomechanics are affected at a minimum, which can lead to a chronic injury. Last but not least, I always recommend seeing a specialist that knows about these types of injuries.

References1. Mair SD, Seaber AV, Glisson RR, Garrett WE Jr. The role of fatigue in susceptibility to acute muscle strain injury. Am J Sports Med. 1996 Mar-Apr;24(2):137-43.2. Hammer WI. Functional soft tissue examination and treatment by manual methods. Aspen Publishers; 1991

Monday, July 6, 2009

Yao Ming's Foot Injury

After limping off of the court in this past years Western Conference Semi Finals against the Lakers, who would of thought that Yao Ming would be looking at a season, potentially career ending injury?

Yao has been diagnosed with a stress fracture of the left foot. More specifically he has fractured a small bone located at the top arch of the foot, called the Navicular.

A stress fracture is a common overuse injury most often seen in athletes. It usually occurs when the forces are much lower, but happen repetitively for a long period of time; these injuries are also known as "fatigue fractures." Stress fractures are commonly seen in athletes who run and jump on hard surfaces, such as distance runners, basketball players, and ballet dancers.
A stress fracture can occur in any bone, but is commonly seen in the foot and shin bones (

Here's a great video from ESPN describing, in further detail, Yao's injury:

Treatment of a stress fracture typically includes but not limited to:
Muscle Stimulation
Soft Tissue Therapy
Graston Technique
Therapeutic Ultrasound
Stretching and Strengthening Exercises
*Surgery if necessary

Of the above listed treatments, rest and immobilization are without question, the most important. This is needed to allow the injury to fully heal. If it doesn't heal properly, and the athlete starts playing again, that area can become susceptible to further injury. Or worse yet, other areas of the foot can pick up the unnecessary slack, and become injured themselves. This can ultimately start, or in Yao's case, continue a cascade of problems.
Now I know its difficult to keep a Starting Center/NBA Icon/Hero from China off the basketball court, but it is definitely necessary. Stress fractures take time to heal, and can become a nuisance if they don't heal properly.
Hopefully Yao choose's the correct course of treatment, and is given the appropriate amount of resting time. Even though it may take a while for him to get back on the court, we are all routing for him to have a long and successful career.