Tuesday, September 29, 2009

Supervised exercises are more effective than shockwave treatment to relieve chronic shoulder pain, finds a study published on bmj.com

Supervised exercises are more effective than shockwave treatment to relieve chronic shoulder pain, finds a study published on bmj.com.

Shoulder pain is the fourth most common type of musculoskeletal pain reported to general practitioners and physiotherapists. Treatments often include physiotherapy, non-steroidal anti-inflammatory drugs, and steroid injections. Physiotherapy can include shockwave treatment, ultrasound, exercises and acupuncture.

Several studies have suggested that shockwave treatment may not be effective, but it continues to be used widely.

So a team of researchers based in Oslo, Norway compared the effectiveness of radial extracorporeal shockwave treatment (low to medium energy impulses delivered into the tissue) with supervised exercises in patients with shoulder pain.

The study involved 104 men and women aged between 18 and 70 years attending the outpatient clinic at Ullevaal University Hospital in Oslo with shoulder pain lasting at least three months.

Participants were randomised to receive either radial extracorporeal shockwave treatment (one session weekly for four to six weeks) or supervised exercises (two 45 minute sessions weekly for up to 12 weeks).

Both groups were similar at the start of the study with regard to age, education, dominant arm affected and pain duration.

All patients were monitored at six, 12 and 18 weeks and were advised not to have any additional treatment except analgesics (including anti-inflammatory drugs) during the follow-up period. Pain and disability were measured using a recognised scoring index.

After 18 weeks, 32 (64%) of patients in the exercise group achieved a reduction in shoulder pain and disability scores compared with 18 (36%) in the shockwave treatment group.

More patients in the exercise group returned to work, while more patients in the shockwave treatment group had additional treatment after 12 weeks, suggesting that they were less satisfied.

These results are in agreement with results from previous trials recommending exercise therapy and do not strengthen the evidence for extracorporeal shockwave treatment, say the authors.

They conclude: "Supervised exercises were more effective than radial extracorporeal shockwave treatment for short term improvement in patients with subacromial shoulder pain."

Link to paper

British Medical Journal

Monday, September 28, 2009

Acupuncture Relieves Pain in Patients with Osteoarthritis of the Knee

Acupuncture Relieves Pain in Patients with Osteoarthritis of the Knee


Acupuncture, Electro-Acupuncture, Chinese Medicine, Traditional East Asian Medicine

Reference:“Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee,” Ahsin S, Saleem S, et al, Pain, 2009; Sept 17; [Epub ahead of print]. (Address: Department of Physiology, Army Medical College Rawalpindi, Pakistan; Department of Natural Sciences, School of Health and Social Science, Middlesex University, UK).
Summary:In a single-blinded, sham-controlled study involving 40 patients (male and female) with primary osteoarthritis of the knee, daily treatment with acupuncture (electro-acupuncture) for a period of 10 days was found to significantly improve WOMAC scores (Western Ontario and McMaster Universities) and pain, according to visual analogue scale scores. In addition, a significant rise in plasma beta-endorphins and a significant decrease in plasma cortisol levels were found. These results suggest that treatment with acupuncture, specifically electro-acupuncture as used in this study, was found to reduce pain, stiffness and disability, over a period of 10 days. The authors conclude, “Of clinical importance is that an improvement in objective measures of pain and stress/pain associated biomarkers was shown above that of a sham treatment...” demonstrating that the beneficial physiological effects of acupuncture go beyond that of a placebo effect.

Friday, September 25, 2009

T-Mac's Injury Recovery

T-Mac's back thanks to Chicago gym

McGrady glad he listened to wife
September 16, 2009, 10:31 PM
By: Nick Friedell

Tracy McGrady came all the way to Chicago to seek redemption. The seven-time all star has been in town for several months after having micro-fracture knee surgery earlier in the year. He spends most of his days rehabbing at ATTACK Athletics on the West Side and is convinced all the extra work he's put in this summer will turn him back into the player he once was. The ironic thing is that it took a lot of people to get McGrady to finally give the rehab facility in the Windy City a try.

His former teammate Luther Head tried to get the 30-year-old to give Tim Grover and his staff a chance, but he was unsuccessful, McGrady was too loyal to his trainer of 11 years, Wayne Hall.

"[Tracy] asks me now, [saying], 'You should have put a gun to my head and made me come,'" Head said during a training session last month.

Tim Grover watches Tracy McGrady work on his legs.
It wasn't until McGrady had a conversation with his wife that made him change his mind. Now he's glad that he has.

"If I was from Chicago I would have been in here [from] Day 1, without a doubt, I would have been in here Day 1," he said, acknowledging that Head tried to show him the way a few years ago. "I just refused to come and I'm really kicking myself in the [butt] for not coming. But yeah, I definitely recommend this [process] because it could prolong your career and it could make you a much better player."

McGrady has been working with Grover and physical therapist David Reavy for weeks trying to get himself back into playing shape. Reavy is so convinced of the progress that he suggested recently that the Rockets superstar could be ready to go by October 1 and back in the lineup when the season starts, a recovery plan that would have him healthy weeks in advance of the average patient. Reavy and company have been working on a plan to even McGrady's body out again.

"His whole body was imbalanced from basically his shoulder blades down to his feet," Reavy says. "He was developing a lot of back problems ... He was developing strength in an imbalanced fashion. And what I see in Tracy, in general, he had no core strength, he couldn't hold a plank."

So Reavy and Grover devised a rehab plan that would help bring it all back -- the work is already paying dividends.

"[Tracy] took a hard fall seven years ago in 2002 and he said he was never able to dunk off his left leg [since]. We got him dunking off his left leg four and a half months post micro-fracture, which is basically unheard of," Reavy says. "The results that we get here are basically unprecedented because we take the force off the injured area, we make the body absorb the force equally, so that it can heal properly and faster without the loading that it's constantly getting before.

We took the force off the knee. The knee's not absorbing the force like it was before. Tracy was playing in pain. When I talked to him initially, he said his pain was 8-9 on a scale of 10. An athlete as the ability to block that pain out, but knows he can't push it, so once you take that pain away, they can perform at that level again, because the pain is what really limits them. If you have pain in a certain area you don't know if it's gonna tear. You don't know. Your worst fear as an athlete is to get injured, but if you have that pain, that's gonna limit your body's performance, 'cause you have that in the back of your head, "Oh, I can't cut this way, I can't cut that way, I can only go this way." It limits your dynamics as a player and it's easier to defend you if you're only one dimensional."

If McGrady's recent workouts are any indication, it would be easy to assume that his game will have all of its dimensions back this season.

"I think he's gonna be a player like he used to be in his younger days, because his body is balanced now," Reavy says confidently. "He's using all his muscles properly and everything's absorbing a force and creating a force versus just the knee."

Once he gets over any lingering doubts in his mind, Reavy is convinced that McGrady could return to an All-Star level as soon as this year.

"Tracy's surprised by some of the things he can do, but the fact that he is surprised, means in the back of his mind, there's still something there," Reavy says. "Once I think he gets out there for the first time, I think that confidence level will build even more."

I caught up with McGrady last month during his one of his rehab sessions and we touched on a number of topics, here are some of the other things he had to say:

How is this work different than any of the other places you've been?

Tracy McGrady: I think in the past, I didn't have the type of treatment that I get from Dave. I didn't have the physical therapy part of the treatment. In the past, it was just basically strength and conditioning, lifting weights and stuff on the basketball court. I didn't have this other stuff to come to, making sure after a workout, making sure my muscles are still firing after my workout, after I've done basketball court work. They got a great formula here, I wish I had been a part of this a long time ago. I can't discount what my trainer Wayne Hall did for me the past 11 years, that's who I was training with back in Toronto, back in Houston, back in Orlando.

Why make the switch?

TM: Number one, I had to move here to Chicago, 'cause that where I had surgery. Because I had micro-fracture surgery; this is a surgery that can end your career or you can come back from it, and I wanted to be by the books on my rehab -- that's why I stayed closer to my doctor to make sure he could monitor everything that I'm doing, plus, you got Tim Grover here and he has a great physical therapist and David Reavy. I got the best of both worlds going for me right now. I got the best doctor that I had do my surgery and then I got the best trainer and the best physical therapist.

You could have gone anywhere in the world for rehab. What was the determining factor that brought you here?

TM: Well, I think Tim's track record speaks for itself. It's funny though that you say that. It took me a while to actually train with Tim. I didn't want to do it, my wife, talking to Tim, they had conversations way before I even met Tim or even talked to Tim on the phone, my wife used to try to get me to come here for the longest [time], I was just so loyal to my guy, I didn't want to [leave], but I figured I had to do it this year because I had surgery here and this where I wanted to stay in the offseason to train. I actually started to train with somebody else before I trained with Tim. I was over at John Hall Studios, it's like a private studio and I was working with a guy out of his training facility and I was like, "What the hell?" I finally gave Tim a shot and I'm glad I did it, 'cause I'm far ahead of schedule and I'm feeling pretty damn good.

From the time you first walked in the door here to now, where do you feel like you're at physically?

TM: I feel that I am not that far away from being back on the basketball court. Coming in here, I was so far, so far behind. I shut it down way back in February, but I was never even healthy even after my arthroscopic surgery, back of [2008] in May. I played through this season hurt, injured. When I got here with these guys, [shoot] I think after the first week when I was working with [Dave] I was feeling good, I was like, "Damn," 'cause he was getting other muscles to fire on my body that hadn't fired in a long time, so that's when I started to gain confidence in these guys and it just took off from there.

You've heard all the doubters saying that they don't know if you can make it back to being the player you used to be. Is the pain you're enduring during rehab all the motivation you need and do you feel confident that all the work you've put in here can get you back to the same level you were at?

TM: I'm not necessarily worried about the doubters saying anything. If they feel like I can't back to the player I once was I don't care about that. That's not gonna motivate me. What motivates me is I'm not finished. I got some unfinished business left on the court. I'm not happy the way last season went, so that's motivation in itself. I know what I'm gonna do and what I'm gonna get back to, so I know where I'm gonna be. Once I leave this place and I'm healthy, I'm gonna be ready because I'm not satisfied the way last season went.

Do you think with the type of treatment you're getting now, you're going to have to come back to the facility later, or once you finish rehab this summer you'll be good to go for the duration?

TM: That's a great question. That's a question for my guy right here, [points to Reavy] because I don't know, I don't know how this treatment works. I don't know ... when I leave from here would I be good?

"Pretty much, yes," Reavy responds. "The example that I'll give is Dwyane Wade. Obviously, if you're playing 82 games, and you're playing first quarter to fourth quarter and overtimes as well, any time you're gonna overuse your body and have some [soreness], but the bottom line is through the exercises that I'm gonna give him and make sure that he keeps doing them before he plays, that will help activate muscles and ensure confidence in him as well. He'll feel a difference after he does those exercises, [to] make sure everything is moving, firing properly.

"Your body adapts to the situation it's in, so if you're sitting for a long period of time, you're gonna wake up stiff. You've gotta make sure that tightness leaves so you activate the muscles that have turned off because of the tightness."

How much different is the stuff you're doing here, compared to the stuff you've done your whole career with your old trainer?

TM: It's a lot different because the stuff I'm doing here I never did before. Ever. This is the first time I did it. Everybody have their own ways of training, and like I said, my [old trainer] had his little [regiment] and [shoot], it made me a seven time All-Star. So, I can't discredit what he did, but this is all different and this what's gonna work for me now. That worked for me for 11 years, this is now. I'm a lot older and my body is taking a different turn and this is what it is now, so they each have different ways of training and doing physical therapy, [and] they all work, but this is totally different and this seems to be working a lot better.

Do you ever look down at something like that and go, "Huh?" How are all these weird looking objects helping you out? [Note: At this moment, McGrady is being prodded by a corkscrew looking device]

TM: When you have surgery, you got all that scar tissue in your knee, that tool right there is breaking that [stuff] up in there. When I first saw him do this [stuff] I was like "What the [heck] are you doing?" I didn't even know what it was for, this little tool, doing this little leg movement right here. I'm like "What are you doing?" It's actually helping, 'cause before, I had so much scar tissue in there that now my knee, after doing this for so long, is a lot looser now.

What does the Rockets organization say to you, if anything, about training here compared to anywhere else?

TM: Nothing. I think they trust me. I've been doing this for a long time. It's not like I'm some rookie or some first-year guy. I've been doing this for, this will be 13th year, and every year pretty much, I came into camp in the best shape out of all my [teammates] so they trust that I'm doing the right thing and I made the right decision.

Do you feel like the treatment here is adding more years onto the back end of your career as we speak?

TM: Yeah. I definitely feel that. Even now, I feel my body waking up in the morning, just feels a lot better. I used to be sluggish waking up in the morning, like, "Damn, I gotta go work out today?" I actually feel good waking up every morning so this is not a ... there's not been a morning since I've been here, waking up and feeling sluggish. My body feels a lot younger.

I know you've got to rehab, but is there ever a point where you're like, "Damn I've got to wake up again," or is it just part of the process to come back?

TM: It's just part of the process, but I look forward to getting better. That's what it's really all about. I look forward to getting better. I'm foaming at the mouth to back back onto the basketball court. I'm ready to compete. I miss that, man. I miss the whole competitiveness about it. In the past, I was dealing with this knee issue. It was just so frustrating it kind of took the fun out of waking up and looking forward to playing a basketball game, 'cause I knew I couldn't be at my best. Now, I feel that I'm getting back to being my best. I'm looking forward to competing every night.

During your time in the league have you been part of a place that had more competitive runs during the summer?

TM: No. I never play in the summer. I never play basketball in the summer. So this is the first time I've seen guys ... being in a place consistently, where they run every day. I always do individual workouts, I never played.

Is there something to be said for that? Can it work both ways? Or once you get to a different stage in your career, do you have to continue to play every day?

TM: Well, let's see, for seven out of my what, 12 years I made the All-Star team just working out individually (laughs) so [shoot] I think it worked for me. I think everybody approaches it differently. I just felt like improving my individual skills is better than just being out there going up and down playing basketball. I know I could do that. Some guys just do it to get in shape, I do other things to get in shape.

Is there any part of this entire process that's surprised you?

TM: Yeah, yeah. [David's] physical therapy, just everything that he does. All his exercises, [stuff] he makes me do that activate different muscles and instantaneously I can see a difference. I can notice that some [stuff] is working and that's crazy. You go through the years and you try all these different types of strategies from other [physical therapists] and [most stuff] just don't work. Maybe temporarily ... but I've been here six months and my [program] has been consistent. I feel good and I haven't backtracked.

So you can already tell you're coming back?

TM: Already tell.

See the article at Espn.com

Here's a reminder of what a healthy T-Mac can do

Thursday, September 24, 2009

Knee pain, Cycling, kinesio tape and Cold class III laser Now What?

The knee is a common site for injuries for cyclist. When you consider the amount of work it takes as we pedal around and around it's amazing that we use it to rehab knees in my office for people with a host of other injuries that are not cycling related. The knee is a complex biomechanical piece of machinery. When structures are not functioning properly, the knee will let you know with a nice dose of pain. There are many conditions and outside factors that can affect the knee. In this article, I have combined two patients with similar complaints, into one patient with a functional problem.
A patient presents to my office with bilateral knee pain that is present after riding his road or mountain bike. He has recently purchased his road bike to add to his training and the problem occurs soon after that. Review of his past medical history is non contributory and family history is benign as it relates to his present condition. After finishing his history I proceed to examine him and his physical exam is normal as well as vital signs. He is in his 20's, physically fit and has been riding for several years. He has recently started training harder. Range of motion is full in all planes, his arches and gait is 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 began to palpate (touch) his patella tendon just below his knee cap when the patients says "that's it doc, that's tender" I continue to feel around his knee and find no other finding. Next step, he has brought his bike and shoes so I take a look at his cleats and they are way off. The patient is basically riding on his toes, which is not good and his right cleat is rotated internally way too much. I then examined his position on the trainer and took some measurements and dropped a plumb line and his saddle was to low as well as to far forward etc. I have no idea how he was making that bike move forward. The best part he got a "free" bike fit with the purchase of his new bike. Needless to say he needed a proper bike fitting and some treatment for what looks like patellar tendonitis.
So, what are the indications that you might have this problem? Well first, the pain is just below your knee cap on the tendon that attaches your patella to a bump at the top of the shin called the tibial tuberosity (fig1). It can be at any point along this tendon. You may also have difficulty walking up and down stairs or notice the pain when you step off a curb. You can get swelling but this is not common and could mean you have some rupture of the tendon or fracture that needs further evaluation. This can occur at the patella or at the tibial tuberosity. The pain can occur when after a hard ride.
Why and how does this happen? Well for one, pushing a large gear for extended periods of time or doing long and hard climbs that can be made even worse if you are pushing a large gear. In addition, one should take into account the fact that people tend to jump into hard efforts or extended amounts of saddle time before their body has a chance to adapt to the change. That's why we have the 10% rule to let your tendons, ligaments, and bones adapt. There are patients who have improper recovery, not enough sleep, poor nutrition, or lack of recovery rides. Of course the bike fit can be a problem if the saddle is to low or if your cleats are not positioned properly. Also too much float can cause your knees to have to do too much work in stabilizing the area and this can lead to an increased tensile pressure at the patella tendon. Also, watch what you are doing off the bike (ie; heavy squats, kneeling for long periods of time, playing basketball, and riding can overload the area).
Okay, back to the patient, I made some quick bike adjustments and sent him to a great bike fitter named Chris at "The Bike Doctor" in Waldorf Maryland who made a few more adjustments to his position. In addition, I began to give him some treatment and recommendations based on my idea of the six pillars of recovery.

1. Awareness of state: monitor your overall health
2. Rest: Sleep, Naps, down time
3. Play: Make sure you have time for friends and family etc. Don't burn yourself out
4. Nutrition: Food and supplements
5. Physical: Chiropractic, physical therapy and massage
6. Psychological: Positive mindset, visualization and sports psycology

In this case we will focus on the Physical components of what we did with this patient. We used kinesio-tape as seen in fig 2. Kinesio-tape is used to take some of the pressure off the tendon and also aids in speeding up the healing process. Next, I used a low level laser or cold class III laser that will not heat or destroy tissue, but in fact speed up the healing process. I also performed some soft tissue work on the tendon and muscles of the knee. I adjusted(manipulated)the knee and ankle joints to make sure we had proper alignment and functional biomechanics occurring at the knee and ankle. I had the patient take some time off the bike and then worked him back on staying away from the hills and low cadence. I also had him perform ice massage to the area 3 times a day for 5 minutes, which is much quicker and better than using an ice pack for this condition. We made some diet recommendations and added a supplement to help with recovery. We also ordered some x-rays to make sure that the patella was not degenerating and to rule out some other possible issues. Other tests a sports doctor may order are an MRI, CT, and/or Bone Scan to further evaluate the knee and other conditions such as structural deviations or tears to soft tissue.

Another aspect of knee conditions I would like to point out concerns many younger athletes. A condition called Osgood-Schlatter's disease, that occurs mostly in young athletes and adolescence, where they experience marked pain in the knees. A hallmark of this condition is pain right on the tibial tuberosity, which is the bump on the shin. If a young athlete continues to exhibit persistent pain in the knees, he/she should consult a doctor and be evaluated for Osgood-Schlatter's disease.

In conclusion, my suggestion would be to follow these rules and stay out of my office:
1. Proper bike fit
2. Follow the 10% Rule
3. Good nutrition, such as eating plenty of fruits and vegetables
4. Proper recovery
5. Get help early and see a good sports Doctor

As I have mentioned before, I have used two different patient scenarios and have unfolded their conditions into one for the purpose of this article. After the proper bike fitting, and the treatment of adjusting, the application of kinesio-tape for tissue stabilization, and laser therapy, the cyclist responded quite well. The adjustment to his bike gave him a quick recovery due to the decreased stress put on his knees. I also suggested that stretching be included in his treatment in order to stabilize and help maintain his biomechanics. This included stretching of the gluts/piriformis muscle, the quads, the hamstrings, and the iliotibial band (ITB band) with a foam roller, in a side lying position. It is important to maintain flexibility and strength while riding, which can prevent further injury. In conjunction with the proper nutrition and essential recovery, the bilateral knee pain diminished considerably and he was able to get back on the bike and resume his rides better, with proper form, and more importantly, with less pain.

1. Orthopaedic Testing; Gerarad, Janet A., Kleinfield, Steven L.; Churchhill Livngstone Inc.; 483-578.
2. Knee Pain and Disability; Caillet M.D., Rene; F.A. Davis Company; 3; 143-179

1. This picture shows the knee with a black marker indicating location of the patellar tendon.
2. This is an example of the applying of Kinesio-tape for patellar tendonitis.

Tuesday, September 22, 2009

Graston Technique for Sports Injuries

Here's a quick summary of the Graston technique from their website...

The Graston Technique® is an interdisciplinary treatment used by nearly 5000 clinicians—including athletic trainers, chiropractors, hand therapists, occupational and physical therapists. This technique is utilized at some 550 out-patient facilities and industrial on-sites, by more than 90 professional and amateur sports organizations, and is part of the curriculum at 21 respected colleges and universities.

The Graston Technique utilizes six stainless steel instruments to assist in therapy. The curvilinear edge of the patented instruments combines with their concave/convex shape to mold the instruments to various contours of the body. This design allows for ease of treatment, minimal stress to the clinician's hand, and maximum tissue penetration.

These instruments, much like a tuning fork, resonate in the clinician's hands allowing them to isolate adhesions and restrictions, and treat them very precisely. Since the metal surface of the instruments does not compress, deeper restrictions can be accessed and treated. Just as a stethoscope amplifies what the human ear can hear, these instruments significantly increase what the human hands can feel.

How it works:
-Separates and breaks down collagen cross-links, and splays and stretches connective tissue and muscle fibers.
-Increases skin temperature while facilitating reflex changes in the chronic muscle holding pattern.
-Alters spinal reflux activity (facilitated segment).
-Increases the rate and amount of blood flow to and from the area.
-Increases cellular activity in the region, including fibroblasts and mast cells.
-Increases histamine response secondary to mast cell activity.

The Graston Technique Instruments, while enhancing the clinician's ability to detect fascial adhesions and restrictions, have been clinically proven to achieve quicker and better outcomes in treating both acute and chronic conditions, including:

Cervical (Neck) Sprain/Strain, Lumbar (Low Back) Sprain/Strain
Carpal Tunnel Syndrome, Plantar Fasciitis
Lateral Epicondylitis (Tennis Elbow), Medial Epicondylitis (Golfer's Elbow)
Rotator Cuff Tendinitis, Patellofemoral (Knee) Disorders
Achilles Tendinitis, Fibromyalgia
Scar Tissue, Trigger Finger
Shin Splints, Hip Disorders
Adhesive Capsulitis (Frozen Shoulder), Ankle Sprain
IT Band Syndrome, Among Many Other Conditions

For more information, please visit www.grastontechnique.com or consult with one of our
health care professionals!

WADA Executive Committee Approves 2010 Prohibited List

WADA Executive Committee Approves 2010 Prohibited List

At its September 19, 2009, meeting, WADA’s Executive Committee approved the List of Prohibited Substances and Methods for 2010. The new List will now be officialized and published on WADA’s Web site by October 1, 2009. It will take effect on January 1, 2010.

The Prohibited List is one of the cornerstones of the harmonized fight against doping. It specifies substances and methods prohibited in sport. Its implementation is mandatory for organizations that have adopted the World Anti-Doping Code.

“The annual revision of the List is an elaborate and dynamic process involving international scientific experts and the solicitation of input from stakeholders so that changes are founded on expanding anti-doping knowledge, evidence from the field, and constantly growing understanding of doping practices and trends,” said WADA’s President John Fahey. “This process is highly consultative and WADA’s role is one of facilitation. I am satisfied that, once again, the 2010 List reflects the latest scientific advances.”

The development of the List begins with the circulation of a draft to stakeholders for comment. Comments received are considered by WADA’s List Committee, who then presents its conclusions to WADA’s Health, Medical and Research Committee. The latter in turn submits its final recommendations to the Executive Committee, who discusses the recommendations and makes a final decision at its September meeting.

Change of Status for Salbutamol

The 2010 List offers a number of changes compared to the 2009 List. In particular, the status of salbutamol, a beta-2 agonist, will change. Salbutamol – a substance considered as specified and therefore more likely to result in a sanction of a warning to a two-year ban in case of anti-doping rule violations – will be permitted under 1,000 nanograms per millilitre. Under the 2010 List, its use by inhalation will no longer require a Therapeutic Use Exemption (TUE) but rather a simplified declaration of use. This measure will allow the handling of salbutamol by anti-doping organizations in a more cost-efficient way.

In addition, the 2010 List will no longer prohibit supplemental oxygen (hyperoxia). The status of platelet-derived preparations (e.g. Platelet Rich Plasma, “blood spinning”) has also been clarified. These preparations will be prohibited when administered by intramuscular route. Other routes of administration will require a declaration of use in compliance with the International Standard for TUEs.

Pseudoephedrine Reintroduced
Another noteworthy amendment is the reintroduction of pseudoephedrine to the List as a specified stimulant – a category of substances that is more likely to result in a sanction of a warning to a two-year ban in case of anti-doping rule violations.

Until 2003, pseudoephedrine was prohibited in sport. Pseudoephedrine was subsequently included in WADA’s Monitoring Program in 2004. The Monitoring Program includes substances that are not prohibited in sport but are monitored in order to detect patterns of misuse.

Results of the Monitoring Program over the past five years have shown a sustained increase in samples containing pseudoephedrine concentrations of more than 75 micrograms per millilitre. The Program indicated clear abuse of this substance with high concentrations in a number of sports and regions. In addition, available literature shows scientific evidence of the performance-enhancing effects of pseudoephedrine beyond certain doses.

Based on literature and results of controlled excretion studies funded by WADA, pseudoephedrine will therefore be reintroduced in the List starting on January 1, 2010, with a urinary threshold of 150 micrograms per millilitre. Given the wide availability of medicines containing pseudoephedrine, WADA’s Scientific Committees and Executive Committee recommended that the reintroduction of pseudoephedrine be accompanied by information and education campaigns by WADA’s stakeholders.

New Scientific Research Projects

As is traditionally the case at its September meeting, WADA’s Executive Committee approved scientific research projects for funding.

“Scientific research is one of WADA’s key priorities,” said John Fahey. “Our Research Grant Program allows us to enhance current detection means and to fund reactive research to ensure that quick response is made to new substances or methods that are being used by cheaters. It also contributes to anticipating doping trends and developing detection means before new doping substances or methods are made available to athletes. Our growing cooperation with pharmaceutical and biotechnology companies, as well as drug agencies and evaluation bodies, is a good example of how we strive to stay ahead of drug cheats.”

A record number of research proposals (88) were received this year from 22 countries, with 34 being selected for funding by WADA’s Scientific Committees and Executive Committee. These projects will help advance anti-doping research in such areas as the detection of blood manipulations, the development of new technologies of detection and the implementation of further means for detecting a number of substances and methods currently abused by athletes or potentially interesting to cheaters. Project descriptions will be posted on WADA’s Web site once the contracts have been signed.

Monday, September 21, 2009

Antioxidants Reduce Inflammation

Antioxidants Reduce Inflammation

Keywords:INFLAMMATION - Antioxidants, Coenzyme Q9, Coenzyme Q10, Alpha-Tocopherol, Vitamin E, Beta-Carotene

Reference:“Naturally occurring antioxidant nutrients reduce inflammatory response in mice,” Novoselova EG, Lunin SM, et al, Eur J Pharmacol, 2009; 615(1-3): 234-40. (Address: Institute of Cell Biophysics, Russian Academy of Sciences, Pushchino, Moscow Region 142290, Russian Federation. E-mail: elenanov_06@mail.ru ).
Summary:In a study involving NMRI male mice, supplementation with the fat-soluble antioxidants, coenzyme Q9, alpha-tocopherol, and beta-carotene, for 15 days prior to being induced with acute inflammation (through lipopolysaccharide injection - which induced production of pro-inflammatory cytokines) was found to significantly reduce the level of inflammation induced by the lipopolysaccharide injection, as compared to levels found in mice who did not receive the antioxidants. In addition, antioxidant treatment was associated with a significantly reduced expression of the inducible form of heat-shock protein 70, induced by the injection as well. The authors conclude, “In this report we demonstrate the potential effectiveness of naturally occurring antioxidant nutrients in the reduction of the inflammatory response. Therefore, it may be possible to develop novel therapeutic combinations, containing coenzyme Q(9), alpha-tocopherol, and beta-carotene, which promote immune stimula tion.”

Friday, September 18, 2009

Surgery for Shoulder dislocation new study.

Arthroscopic surgery successful in active patients for over a decade

SAN FRANCISCO, 8-Mar-2008 -- Young, athletic, first-time shoulder dislocation patients benefit from arthroscopic surgery long term, according to a study released today at the 2008 American Orthopaedic Society for Sports Medicine Specialty Day at The Moscone Center. The study found that for highly active patients, surgery, rather than conservative methods, yielded excellent results.

“In young, active patients, there were statistics as high as 92 percent that they would dislocate their shoulder again when conservative approaches like rest and immobilization in a sling were used,” says Robert A. Arciero, MD, of the Keller Army Hospital in West Point, NY. “If we had an operation with a 90 percent failure rate, we would abandon the procedure. My thought was, why should we embrace a treatment with such a high failure rate”.

Beginning in 1993, Dr. Arciero began performing arthroscopic surgery on young military cadets who suffered their first shoulder dislocation. The short-term results were excellent. The unknown, however, was how these patients would fare over the years.

“We decided to examine these patients’ long-term results,” says Major Brett Owens, MD, of Williams Beaumont Army Medical Center in El Paso, Texas. “We found that these patients maintained their health and active lifestyle. Surgery for this group of patients was durable and provided excellent shoulder function and a high activity level even after 10 years.”

Owens and his colleagues evaluated 39 patients (40 shoulder operations) whose follow-up averaged 11.7 years. Patients were evaluated with patient-derived outcomes measures and asked to compare their repaired shoulder to its function level pre-injury and whether they would be likely to have the surgery again. Additionally, they were physically assessed with a number of tests, including, how many push-ups they completed in two minutes and performance on the Army Physical Fitness Test.

Overall, the study found that the patients maintained excellent use of their shoulder. The mean American Shoulder and Elbow Surgeons score was 90.9. The patients compared their repaired shoulders’ function to the pre-injury function. The average response was 93 percent, the study found. When responding to whether they would have the surgery again with 10 being “very likely,” the average score was 9.1, according to the study.

In terms of athletic ability, the results were also notable. The study found the average number of push-ups performed in 2 minutes was 72.8 compared to 77.7 prior to their injuries. The mean score of the Army Physical Fitness Test was 282.2 out of a possible 300, according to the study.

The study also noted five patients who had eight further dislocations, all of which occurred during athletic activity, for a failure rate of 10 percent long-term.

“Certainly our study proves that for this group of patients, young, athletic cadets unable to modify their activity level, arthroscopic surgery for first-time dislocations is successful both short and long-term,” says Dr. Owens. “This treatment allowed our patients to return to sports, graduate from the military academy and engage in active duty military obligations. It may not be the approach that should be taken for a person who lives a sedentary lifestyle, but this could be applicable to the young, 15-25-year-old athlete, who is at high risk for recurrent instability and compromised function”

The American Orthopaedic Society for Sports Medicine (AOSSM) is a world leader in sports medicine education, research, communication and fellowship, and includes national and international orthopaedic sports medicine leaders. The Society works closely with many other sports medicine specialists, including athletic trainers, physical therapists, family physicians, and others to improve the identification, prevention, treatment, and rehabilitation of sports injuries.

For more information, please contact AOSSM Director of Communications, Lisa Weisenberger, at 847/292-4900 or e-mail her at lisa@sportsmed.org. You can also visit the AOSSM Web site at www.sportsmed.org.

Thursday, September 17, 2009

Robbie McEwen Knee Surgery

Australian sprinter Robbie McEwen said who missed the Tour de France after breaking his tibia (shin bone) in Belgium. McEwen said on his Twitter feed a few months back that he had surgery on his leg and will probably be back on the bike by September.

McEwen, who has won the green jersey for leading sprinter in the Tour de France three times, broke his left tibia when he hit a road sign in a tumultuous finale of the second stage of the Tour of Belgium. Doctors inserted two screws to repair the leg but the recovery period ruled out participation in the Tour, which begins on 4 July.

McEwen, who races with the Katusha team, has had a bad run of luck this season starting in January's Tour Down Under when a fan leaned too far over the barriers with a camera lens than smashed into McEwen's arm during a sprint for the finish line.

In April he suffered concussion and other injuries in a crash in the Scheldeprijs Vlaanderen race in Belgium forcing him to abandon plans to ride the Giro d'Italia. He was back in form winning a stage of the Tour de Picardie in France and was racing the Tour of Belgium as preparation for the Tour de France. Even though he was doing all the right rehab the type of crush injury produced a ton of scar tissue that restricted his patella tendon from moving properly. He Tweeted today and posted pics about his second knee surgery.

"look at the inside of my knee. operated yday by Prof.Alfredson in Sweden. scar tissue had adhered + blocked t ..."

"inside of my knee showing scar tissue being removed. it was completely blocked so tendon couldn,t move"

"after removal of scar tissue and new blood vessels.Freed up, this is how a tendon should look. it was stuck a "

"yes i was awake, local anaesthetic. i was watching but someone else took the pics for me. The uni sports centre here in Umea is fantastic!"

Well I want to wish Robbie McEwen a quick recovery and hope to see him sprinting early next season

Tuesday, September 15, 2009

Athletes With Smaller ACLs May Be More Susceptible To Injury

Athletes With Smaller ACLs May Be More Susceptible To Injury

A study comparing images of the knees in people who did and didn't have previous injuries to the anterior cruciate ligament suggests that people who tore their ACLs are more likely to have a smaller ligament than do similarly sized people who have never injured a knee.

Researchers calculated the total volume of the ligaments based on magnetic resonance images of human knees. The ACLs among those with previous injuries were, on average, about 10 percent smaller than were ACLs among those without an injury.

In those with previous injuries, the uninjured ACL in the opposite knee was measured for the study. Their ligaments were compared to the ACLs in uninjured people of similar height and weight.

Those who had torn their ACLs had experienced noncontact injuries, meaning the injury occurred during some sort of movement of the body rather than because of a blow to the knee.

Researchers caution that the retrospective study does not mean that a smaller ACL will necessarily result in injury. Instead, they say the research offers more clues about the variety of factors - such as activity level, neuromuscular coordination, gender and muscle strength - that appear to be contributors to ACL injury.

In this group of participants, weight was the strongest predictor of ACL volume.

"If you compared two people of the same weight, based on our data set, we would expect the injured person had the smaller ACL," said Ajit Chaudhari, assistant professor of orthopedics at Ohio State University and lead author of the study.

Knowing that the knee's anatomy can influence susceptibility should help researchers who are trying to figure out why ACL injuries occur and who is most likely to experience these injuries, Chaudhari said. Most study results guide the assignment of a percentage of risk to one or more factors associated with torn ACLs, but to date no research had looked solely at the size of the ligament in injured and non-injured knees.

The research is published in a recent issue of the American Journal of Sports Medicine.

The anterior cruciate ligament, responsible for rotational stability in the knee, is located behind the kneecap and is one of four ligaments that join the thigh and shin bones. Noncontact tears of the ACL tend to occur in athletes when they pivot, stop quickly or land from a jump. Previous research suggests that college-age women athletes are at three- to 10-times higher risk of tearing their ACLs than their male counterparts, depending on the activity, but scientists have not determined why this is.

"Comparisons of the volumes of ACLs between men and women have been done, which have suggested that ACL volume may matter. Studies have also found that female ACLs had fewer fibers than male ACLs that were tested. But even with those findings, any differences between males and females could be a coincidence. There are so many variables that interact that you can't really tell what's causative unless you compare people who have had an injury to those who haven't had an injury," said Chaudhari, also director of Ohio State's Sports Biomechanics Laboratory.

He and colleagues took MR images of the knees of 54 participants, who were divided into two groups. Volunteers with previous injuries were matched with uninjured participants of the same age, gender, height and weight.

The previously injured participants' healthy knees were imaged for the study. Chaudhari said the fibers of a torn ACL tend to fray like a rope, meaning the volume of injured ACLs could not be measured in a meaningful way. Chaudhari recently presented related research that indicated that there is no significant difference in the size of two ACLs in the same body.

Researchers used the MR images to determine the outline of each ACL under the guidance of an orthopedic surgeon experienced in operating on injured knees. They validated this method of determining ACL volume by practicing the measurement technique on five pig knees obtained from a butcher.

Of the 27 injured participants, 16 had smaller ACLs than their matched controls. Overall, the injured group had an average ACL volume of 1,921 cubic millimeters, while the control group had an average volume of 2,151 cubic millimeters.

In this group of participants, weight and height were strongly correlated as potential variables affecting the size of the ligament.

Chaudhari said that based on what is currently known about the fibrous makeup of the ligament, it's no surprise that a smaller ACL is more susceptible to injury.

"If you have a weaker ACL, it's more likely to tear if all other factors are equal," he said. "If being larger in size means the ACL has more fibers, then that would make it stronger. If the individual building blocks are of similar strength, then it comes down to how much total tissue there is."

It's too soon to consider knee imaging as a way to screen potential athletes, Chaudhari said, because of the high expense and the fact that knowing the size of the ACL still doesn't tell the whole story of how the knee will react to activity.

"I would certainly not say in any way, shape or form that people should start using ACL size as a determinant of whether they should play any sport," he said.

But what it does tell researchers is that there might be more than one way to go about trying to prevent knee ligament injuries. While many prevention efforts focus on the strength of muscles surrounding the knee, Chaudhari and other researchers hope to study whether the ACL itself can be made stronger, or larger, or both, while a child is still growing and developing.

This work was supported by the OSU Roessler Scholarship Fund, the Wright Center for Innovation in Biomedical Imaging, and a National Institutes of Health Clinical and Translational Science Awards grant.

Co-authors are Eric Zelman of the College of Medicine, David Flanigan and Christopher Kaeding of the Department of Orthopedics, and Haikady Nagaraja of the Department of Statistics, all at Ohio State.

Ajit Chaudhari
Ohio State University

: Freshly Crushed Garlic More Cardioprotective Than Processed Garlic

Freshly Crushed Garlic More Cardioprotective Than Processed Garlic
Keywords: CARDIOVASCULAR HEALTH - Garlic, Fresh, Processed
Reference: “Freshly crushed garlic is a superior cardioprotective agent than processed garlic,” Mukherjee S, Lekli I, et al, J Agric Food Chem, 2009; 57(15): 7137-44. (Address: Cardiovascular Research Center, University of Connecticut School of Medicine, Farmington, Connecticut 06030-1110, USA).
Summary: In an animal study involving rats fed either crushed fresh garlic or processed garlic for a period of 30 days, after which they were sacrificed and their hearts isolated and subjected to 30 mins ischemia followed by 2 hours reperfusion, greater cardiac performance was found in the hearts of rats fed the crushed fresh garlic. The authors conclude, “The results thus show that although both freshly crushed garlic and processed garlic provide cardioprotection, the former has additional cardioprotective properties presumably due to the presence of H2S.”

Low Dietary Intakes of Vitamins A and C Linked to Asthma

Low Dietary Intakes of Vitamins A and C Linked to Asthma
Keywords: ASTHMA, WHEEZE - Vitamin A, Vitamin E, Vitamin C
Reference: “Association between antioxidant vitamins and asthma outcome measures: systematic review and meta-analysis,” Allen S, Britton JR, et al, Thorax, 2009; 64(7): 610-9. (Address: Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK).
Summary: In a systematic review and meta-analysis of studies examining the impact of dietary intakes of vitamins A, C, and E on occurrence of asthma, the authors conclude that significantly low levels of vitamins A and C are associated with an increased occurrence of asthma, while levels of vitamin E do not appear to have such an effect. Forty studies were included in the analysis. The data from the studies was pooled and results showed that people with asthma had significantly lower intakes of vitamin A as compared to people without asthma, and people with severe asthma had significantly lower levels than those with mild asthma. Lower dietary intake of vitamin C and lower serum vitamin C levels were also associated with an increased odds of asthma. Vitamin E levels were significantly lower in patients with severe asthma, as compared to mild asthma. The authors conclude, “Relatively low dietary intakes of vitamins A and C are associated with statistically significant increa sed odds of asthma and wheeze.”

Thursday, September 10, 2009

Effect of rye bread breakfasts on subjective hunger and satiety: a randomized controlled trial

Abstract (provisional)


Several studies report that dietary fibre from different sources promotes the feeling of satiety and suppresses hunger. However, results for cereal fibre from rye are essentially lacking. The aim of the present study was to investigate subjective appetite during 8 h after intake of iso-caloric rye bread breakfasts varying in rye dietary fibre composition and content.


The study was divided into two parts. The first part (n=16) compared the satiating effect of iso-caloric bread breakfasts including different milling fractions of rye (bran, intermediate fraction (B4) and sifted flour). The second part (n=16) investigated the dose-response effect of rye bran and intermediate rye fraction, each providing 5 or 8 g of dietary fibre per iso-caloric bread breakfast. Both study parts used a wheat bread breakfast as reference and a randomised, within-subject comparison design. Appetite (hunger, satiety and desire to eat) was rated regularly from just before breakfast at 08:00 until 16:00. Amount, type and timing of food and drink intake were standardised during the study period.


The Milling fractions study showed that each of the rye breakfasts resulted in a suppressed appetite during the time period before lunch (08:30-12:00) compared with the wheat reference bread breakfast. At a comparison between the rye bread breakfasts the one with rye bran induced the strongest effect on satiety. In the afternoon the effect from all three rye bread breakfasts could still be seen as a decreased hunger and desire to eat compared to the wheat reference bread breakfast. In the Dose-response study both levels of rye bran and the lower level of intermediate rye fraction resulted in an increased satiety before lunch compared with the wheat reference bread breakfast. Neither the variation in composition between the milling fractions nor the different doses resulted in significant differences in any of the appetite ratings when compared with one another.


The results show that rye bread can be used to decrease hunger feelings both before and after lunch when included in a breakfast meal. Rye bran induces a stronger effect on satiety than the other two rye fractions used when served in iso-caloric portions. Trial registration number NCT00876785

Virginia Tech Biomedical Engineering Team To Study Knee Ligament Sprains

A team of Virginia Tech engineering researchers has won a $300,000 National Science Foundation grant to study knee ligament sprains at the micro-mechanical level.

Principal investigator Raffaella De Vita, an assistant professor in the engineering science and mechanics department and director of the Mechanics of Soft Biological Systems Laboratory, will examine the role of the structural components of knee ligament in sprains by combining micro-mechanical models, molecular models, and biological and mechanical experiments. Previous biomechanics studies focused on quantifying the macro-mechanical properties of ligaments, such as tangent modulus, tensile strength, and ultimate strain. Yet, little is known of their response to mechanical stimuli that lead to partial and complete ligament failure. The study is expected to clarify micro-structural changes, such as the level of collagen crosslink, associated with partial and complete tears, De Vita said.

The study will focus on the most common orthopedic injuries, such as those caused by when the knee is forced beyond its normal motion range, such as in a fall, or when the knee is impacted during a vehicular accident or participation in sports such as football. These injuries can consist of a slight over-stretch, a partial tear, or a complete disruption of the ligaments.

The study will involve rat specimens of similar age and sex type, but split into two groups - one fed a diet of sweet peas and the other a lethargic diet. Diet affects the crosslinks in collagen, which is the primary makeup of ligaments, De Vita says. Harvested ligaments will be subjected to lab stress tests and their deformation observed by using a special high-speed camera.

Once completed, the research findings could lead to the creation of replacement grafts and biological scaffolds for damaged ligaments. The results also will guide the design of braces or stretching routines to help prevent damage during stressful activities that otherwise would lead to ligament sprains.

Expected research benefits are not solely limited to knees. "The research findings will contribute to understanding the failure mechanism of more complex biological soft tissues such as, for example, skin and arteries" that are comprised of collagen, said De Vita.

Serving as co-principal investigators in the study will be Joseph Freeman, an assistant professor at the Virginia Tech - Wake Forest University School of Biomedical Engineering and Sciences and director of the Musculoskeletal Tissue Regeneration Laboratory, and Jennifer Barrett, an assistant professor of surgery at Virginia Tech's Marion duPont Scott Equine Medical Center. Freeman will focus on molecular modeling, while Barrett will handle molecular biology; all three will work on experimental mechanics.

De Vita earned a laurea degree in mathematics from Italy's University of Naples II in 2000, and masters and doctoral degrees in mechanical engineering from the University of Pittsburgh in 2003 and 2005, respectively.

Freeman earned his bachelor of science in chemical engineering from Princeton University, and his Ph.D. in biomedical engineering from Rutgers University and The University of Medicine and Dentistry of New Jersey.

Barrett received a doctor of veterinary medicine degree from Cornell University in Ithaca, New York, in 2002 and a doctorate in molecular biology from Yale University in New Haven, Connecticut, in 1999.

Steven Mackay
Virginia Tech

Tuesday, September 8, 2009

Tour of Missouri

Day one is complete and the boys from Colavita put in a very hard effort to get our top sprinter Seba Haedo into position to contest for the win or podium. He finished 6th but suspect that he could have been 4th if his momentum was not stopped. On my end just a bit of recovery work using, some streching, adusting, cold laser and of course Graston.

ToM Link

Monday, September 7, 2009

Creatine Supplementation May Improve Performance in Male Swimmers

Creatine Supplementation May Improve Performance in Male Swimmers

ANAEROBIC PERFORMANCE, EXERCISE - Creatine, Swimming, Fin Swimming

“Creatine supplementation improves the anaerobic performance of elite junior fin swimmers,” Juhász I, Tihanyi J, et al, Acta Physiol Hung, 2009; 96(3): 325-36. (Address: Eszterházy Károly College Institute of Physical Education and Sport Sciences Leányka u. 6 H-3300 Eger Hungary Leányka u. 6 H-3300 Eger Hungary).

In a randomized, placebo-controlled study involving 16 elite male fin swimmers (mean age = 15.9 years), results indicate creatine supplementation may increase anaerobic performance. The swimmers were randomized to creatine (CR, 4x5 g/day creatine monohydrate) or placebo for 5 days. At intervention end, the average power of one minute continuous rebound jumps increased by 20.2% in the CR-supplemented group, compared with baseline. Additionally, swimming time measured in two maximal 100 m fin swims significantly reduced in the CR-supplemented group. No significant change was observed in the placebo group. Thus, the authors conclude, “The results of this study indicate that five day Cr supplementation enhances the dynamic strength and may increase anaerobic metabolism in the lower extremity muscles, and improves performance in consecutive maximal swims in highly trained adolescent fin swimmers.”

Saturday, September 5, 2009

Treatment for Ankle Sprains

Here's a great article regarding the causes and treatments of ankle sprains.

Chronic Ankle Pain (Unresolved Ankle Sprain)
By James Brantingham, DC, CCF , Randy Snyder, DC, CCFC, John Wong, DPM, D.C., Charles Brantingham, DPM and Bruce Haggart, DC

Unresolved, chronic ankle pain secondary to ankle inversion sprain is a commonly seen condition. Many mechanisms have been suggested as the reason for chronic ankle pain: lack of appropriate and early immobilization in severe cases; lack of appropriately prescribed mobility and strengthening exercises; development of scar tissue; development of late hypermobility; secondary, continuing aggravation due to unrecognized or untreated hyperpronation; too much immobilization.

Common, acute inversion ankle sprain and its management is first covered followed by diagnosis and treatment of chronic ankle pain. Representative case studies will be presented in Part II of this article (see Feb. 12, 1993 issue).

Common, Acute Inversion Ankle Sprains

Inversion sprain is the most common injury affecting the ankle joint. Injury frequently occurs to the anterior talofibular ligament. The calcaneofibular ligament may also become involved if inversion occurs while the ankle is at a right angle. However, the sprain usually occurs with inversion stress when the foot is also slightly plantar flexed. Occasionally, the posterior talofibular ligament may also become injured.

When the foot plantar flexes, the posterior portion of the talar trochlea advances in the ankle mortise. This creates an added space between the posterior portion of the talus and the malleolus inducing lateral instability. The lateral collateral ligaments are shorter and weaker than the medial collateral ligaments. Additionally, the anterior ankle joint is capsular and the posterior ligaments are thin.1 The calcaneofibular ligament is the only component of the lateral collateral ligaments that is extracapsular and is stronger than the anterior talofibular ligament.

Ankle sprain is commonly seen in the presence of uncompensated rearfoot varus, forefoot valgus, rigid plantar flexed first ray, and the cavovarus foot.2

The intensity of force governs the type of injury produced. Most inversion sprains involve an element of internal rotation and plantar flexion of the foot. Young people tend to tear ligaments and injure epiphysis while older people tend to fracture the lateral malleolus.2 Ligament tears rarely occur in the middle, usually sustaining a tear at either the proximal or distal point of attachment.1 A small bone fragment may be avulsed with the ligament rather than the ligament actually tearing. Therefore, inversion type ankle injuries can tear lateral ankle ligaments, fracture the lateral or medial malleolus, cause separation at the distal tibiofibular syndesmosis, and occasionally fracture the posterior lip of the tibia.2 Ankle stability occurs with rupture and anterior displacement of the talus in the ankle mortise.


Initially, control of swelling must be considered. Effusion favors the formation of adhesions which can delay healing. Swelling should be controlled by application of a firm bandage, cold, rest, and elevation of the leg. Oral anti-inflammatories may also be used to help minimize inflammation.1

Plain film radiographs should be taken immediately to rule out fractures. Stress views are helpful in determining ankle instability due to ligamentous rupture.1

If a strain is diagnosed then daily bandage changes with continuation of ice therapy is helpful. After about four days the cold pack modality can be replaced by immersing the involved area in hot water to the patients tolerance for 10 to 15 minutes daily.

Active nonweightbearing exercises should be started within the first few days, and the patient should put the involved foot and ankle through all the normal ranges of motion. Dispersal of edema, maintenance of muscle tone, and the prevention of adhesions will result if done frequently.1

Chiropractic physiotherapy modalities and treatments, such as ultrasound, whirlpool baths, and iontophoresis, help recovery but are not superior to the ice, heat, and active exercises already mentioned. Please take notice of our additional discussion in this paper on the use of manipulation and mobilization.

Providing there are no ligamentous tears, and that swelling has subsided, the ankle should be taped and weightbearing usage resumed. Taping will help to give stability and prevent further stretching of the ligaments while the healing process continues. Depending on the appearance, function, and pain of the ankle, sports activities should be avoided for one to three weeks.1 Proprioceptive sense can be retrained by coordination and balancing exercises. Additionally, specific strengthening exercises may be used to isolate and improve certain muscle functions.

Treatment of avulsion or tear of the lateral collateral ligament generally involves casting. The cast is generally kept on for 10 weeks and may have a walking heel applied. Occasionally, surgical intervention may be necessary.

It is not our intention to cover in depth this well-known and accepted material on acute sprain and its management. We wish to deal with chronic, recurring or continuing ankle pain secondary to an inversion sprain. (Note: Chronic ankle pain in this paper will mean pain secondary to ankle sprain of more than six months duration and has been resistant to previous orthopedic or podiatric treatment.)

Unresolved, Chronic Ankle Sprain

One common cause of unresolved, chronic ankle sprain is unrecognized and untreated excessive pronation.2 Chiropractic authors have also written about the need to recognize and treat excessive pronation as a cause of chronic ankle sprain.3,4 It also appears to be the consensus within podiatry that unrecognized, excessive pronation is a common cause of chronic ankle pain.5,6,7 The prescription of orthotics has been reported as useful in relieving chronic, unresolved ankle sprains,2,3 and we are in agreement with this consensus although it should be noted that no controlled study, as of this writing, has absolutely proven that orthotics, which correct pronation, will resolve chronic, unresolved ankle sprains.

There are still hyperpronated patients who, despite orthotic therapy, or patients who are not pronated, that have suffered inversion ankle sprain (and do not need orthotics to correct excess pronation) that continue to have chronic ankle pain. These patients have chronic ankle pain due to unrecognized and untreated joint dysfunction.

The primary purpose of this paper is to document effective treatment of unresolved, chronic ankle pain by appropriate diagnosis and manipulative treatment of feet and ankle joint dysfunction.

Michaud published case studies in which marked weightbearing rearfoot inversion, in compensation to a marked secondary forefoot valgus, produced an ankle predisposed to easy inversion sprain -- in essence a hypersupinated foot which could easily "tilt over the edge" into an inversion sprain.2 Michaud outlined the prescription of orthotics that pronate the hypersupinated foot and suggested appropriate manipulative and physiotherapeutic diagnosis and treatment.3 This subject was adequately covered by Michaud and need not be discussed here.

James Brantingham, D.C.
Randy Snyder, D.C.
John Wong, DPM, D.C.
Charles Brantingham, DPM
Bruce Haggart, D.C.
Tarzana, California

Friday, September 4, 2009

Athletic Performance Not Found To Be Enhanced By Popular Supplement Quercetin

The antioxidant quercetin is increasingly being marketed as a supplement that boosts athletic performance, but a new University of Georgia study finds that it is no better than a placebo. Professor Kirk Cureton, head of the department of kinesiology in the UGA College of Education, and his colleagues tested quercetin in a double-blind, placebo-controlled study that assessed a variety of measures, including the ability of muscles to synthesize energy, cycling performance, perceived exertion and strength loss following exercise. The researchers, whose results appear in the early online edition of the Journal of Applied Physiology, found that quercetin did not improve athletic performance in any of the measures they examined. "We did not see any performance enhancing effect of quercetin," Cureton said. "To a certain extent that was disappointing because our hypothesis, based on previous studies in mice, was that we would see positive effects. But our findings are important because they suggest that results from the animal studies shouldn't be generalized to humans." Quercetin is a naturally occurring antioxidant found in the skins of fruits, leafy vegetables, and berries, as well as in black tea, red wine and various fruit juices. It is sold as a supplement in nutrition stores and is an ingredient in sports drinks such as FRS Energy, which is promoted by cyclist Lance Armstrong. In mice, quercetin has been shown to stimulate the production of mitochondria, which are the energy producing components of muscle cells and other tissue. One study found that mice supplemented with quercetin increased their running endurance by up to 37 percent. In humans, however, the results have been mixed. An early and widely-cited study reported improvements in performance during a cycling time trial, but Cureton notes that data from the experimental group was not compared to the control group, making the statistical significance of the finding unclear. Published studies on competitive runners and cyclists have found no improvement in performance. A recent published study by the same researchers who reported mitochondrial and endurance increases in mice, however, found that volunteers who consumed a drink containing quercetin saw a 13 percent improvement in endurance. Cureton said the reason for the conflicting results is unknown, but added that several other studies currently in review for publication also have found no performance-enhancing effect. Cureton and his colleagues hypothesized that the athletes used in the previous studies might not have benefitted from quercetin because they had already maximized their mitochondrial density through aerobic training. To address that possibility, the researchers recruited 30 men who were healthy but not endurance trained and randomly assigned them to either an experimental group or a placebo group. The experimental group consumed a sports drink containing 250 milligrams of quercetin four times a day for up to 16 days, a dose and duration similar to previous human studies and comparable to studies in mice. The placebo group received the same sports drink without quercetin. Because the mechanisms of quercetin's action are unclear, the researchers examined a number of variables in what is the most comprehensive study to date on its effect on athletic performance.

The variables included:

The rate at which muscles synthesize energy after strenuous exercise;

Peak oxygen consumption;

The rate of perceived exertion during cycling;

Metabolic changes, such as the percentage of energy derived from fats and carbohydrates (more conditioned individuals tend to use more fat for energy);

Performance on a cycling test;

and Strength loss following prolonged cycling. Cureton notes that had there been a performance-enhancing effect of quercetin, a sample size of 30 would have been sufficient to detect it. Plant-based compounds related to quercetin, such as resveratrol, have been similarly touted for their health benefits based primarily on animal studies, but Cureton said his findings should serve as a reminder that the gold-standard of science is randomized, double-blinded studies in humans. "The take home message here is that promising results in mice don't necessarily translate to humans," Cureton said.

The research was funded by the Coca-Cola Company.

Source: Sam Fahmy University of Georgia

Thursday, September 3, 2009

Chocolate Milk and Recovery

Soccer players and exercise enthusiasts now have another reason to reach for lowfat chocolate milk after a hard workout, suggests a new study from James Madison University presented at the American College of Sports Medicine annual meeting. Post-exercise consumption of lowfat chocolate milk was found to provide equal or possibly superior muscle recovery compared to a high-carbohydrate recovery beverage with the same amount of calories.

In this study, 13 male college soccer players participated in "normal" training for one week, then were given lowfat chocolate milk or a high-carbohydrate recovery beverage daily after intense training for four days. After a two week break, the athletes went through a second round of "normal" training, followed by four-day intensified training to compare their recovery experiences following each beverage (with the same amount of calories). Prior to the intense training, at day two and at the completion of this double-blind study, the researchers conducted specific tests to evaluate "markers" of muscle recovery.

All of the athletes increased their daily training times during the intensified training, regardless of post-exercise beverage yet after two and four days of intensified training, chocolate milk drinkers had significantly lower levels of creatine kinase - an indicator of muscle damage - compared to when they drank the carbohydrate beverage. There were no differences between the two beverages in effects on, soccer-specific performance tests, subjective ratings of muscle soreness, mental and physical fatigue and other measures of muscle strength. The results indicate that lowfat chocolate milk is effective in the recovery and repair of muscles after intense training for these competitive soccer players.

This new study adds to a growing body of evidence suggesting milk may be just as effective as some commercial sports drinks in helping athletes recover and rehydrate. Chocolate milk has the advantage of additional nutrients not found in most traditional sports drinks. Studies suggest that when consumed after exercise, milk's mix of high-quality protein and carbohydrates can help refuel exhausted muscles. The protein in milk helps build lean muscle and recent research suggests it may reduce exercise-induced muscle damage. Milk also provides fluids for rehydration and minerals like calcium, potassium and magnesium that recreational exercisers and elite athletes alike need to replace after strenuous activity.

Nearly 18 million Americans play soccer, according to American Sports Data, and millions more engage in recreational sports. Many experts agree that the two-hour window after exercise is an important, yet often neglected, part of a fitness routine. After strenuous exercise, this post-workout recovery period is critical for active people at all fitness levels �" to help make the most of a workout and stay in top shape for the next exercise bout. Sweating not only results in fluid losses, but also important minerals including calcium, potassium and magnesium. The best recovery routine should replace fluids and nutrients lost in sweat, and help muscles recover.

Increasingly, fitness experts consider chocolate milk an effective (and affordable and enjoyable) option as a post-exercise recovery drink. The Dietary Guidelines for Americans recommend that Americans drink three glasses of lowfat or fat free milk every day. Drinking lowfat chocolate milk after a workout is a good place to start.

Source: Gilson SF, Saunders MJ, Moran CW, Corriere DF, Moore RW, Womack CJ, Todd MK. Effects of chocolate milk consumption on markers of muscle recovery during intensified soccer training. Medicine & Science in Sports & Exercise. 2009;41:S577.

High school football and wrestling athletes experienced the highest rate of severe injuries

High school football and wrestling athletes experienced the highest rate of severe injuries, according to the first study to examine severe injuries injuries that caused high school athletes to miss more than 21 days of sport participation among a nationally representative sample of high school athletes. Severe injuries accounted for 15 percent of all high school sport-related injuries.

Overall, males experienced a higher rate of severe injuries, according to the study published in the September issue of the American Journal of Sports Medicine and conducted by researchers in the Center for Injury Research and Policy (CIRP) of The Research Institute at Nationwide Children's Hospital. However, this difference was driven by the large number of severe injuries that occurred in football and wrestling. In directly comparable sports, such as soccer, basketball and baseball/softball, females sustained a higher severe injury rate. In all sports studied, severe injury rates were higher in competition than in practice.

"Twenty-nine percent of severe injuries occurred to the knee, making it the most commonly injured body site," explained the study's co-author Christy Collins, CIRP research associate at Nationwide Children's Hospital. "The ankle accounted for 12 percent followed by shoulder at 11 percent."

The most severe and common injury diagnoses were fractures (36 percent), complete ligament sprains (15 percent) and incomplete ligament sprains (14 percent). Commonly fractured body sites included the hand and finger (18 percent), ankle (14 percent) and wrist (11 percent).

"Severe injuries negatively affect athletes' health and often place an increased burden on the health care system," said study co-author Dawn Comstock, PhD, CIRP principal investigator at Nationwide Children's and a faculty member of The Ohio State University College of Medicine. "Future research is needed to develop effective interventions to decrease the incidence and severity of high school sports injuries."

Sports studied included football, boys' and girls' soccer, volleyball, boys' and girls' basketball, wrestling, and baseball and softball. Data for the study were collected from the 2005-2007 National High School Sports Injury Surveillance Study (High School RIO™), which was funded in part by the Centers for Disease Control and Prevention.

The Center for Injury Research and Policy (CIRP) in The Research Institute at Nationwide Children's Hospital works globally to reduce injury-related pediatric death and disabilities. With innovative research at its core, CIRP works to continually improve the scientific understanding of the epidemiology, biomechanics, prevention, acute treatment and rehabilitation of injuries. CIRP serves as a pioneer by translating cutting edge injury research into education, advocacy and advances in clinical care. In recognition of CIRP's valuable research, the Centers for Disease Control and Prevention (CDC) designated the Center for Injury Research and Policy as an Injury Control Research Center in 2008.

Source: Nationwide Children's Hospital