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December 6th, 2008
A few months ago I had the opportunity to treat a recreational but competitive fastball player with a chronic shoulder problem. History included a fall on outstretched arm (in abduction and external rotation) with acute pain in the anterior shoulder. He described the pain as “deep inside the joint” and pointed anterior. I won’t go into the details but let it be said that there was no gross instability and every SLAP orthopedic maneuver in the book tested positive for a labral tear. Also relevant is that he had a previous history of competitive bodybuilding and a significant shrug sign with pain during abduction, and a deficit of internal rotation.
So we proceeded with treatment and two months later all orthopedic tests were negative and he was moving pain free. After further rehabilitation and conditioning he was back to playing competitive fastball at 3 months. This raises some very important questions: Did I fix his torn labrum? Of course not. Were these false positive labral tests? With that history, I don’t think so.
One month later another patient with significant and chronic shoulder pain presented to my office. This case was a confirmed supraspinatous and infraspinatous tear (100% of supra and 80% thickness tear of infra, respectively) as a result of a motor vehicle accident. He presented to my office after having pain and loss of function for 1 year. He had a marked shrug sign with flexion and abduction and a previous history of weightlifting and a marked shrug sign and internal rotation deficit.
So we proceeded with treatment and two months later he reported no pain with flexion or abduction and significant improvement in strength. Did I fix his rotator cuff lesion? Of course not. Was the MRI wrong? As evidenced by the big hole in the supraspinatous and infraspinatous fossa, definitely not.
Fact is many people are walking around, throwing, and lifting their way through life with labral and rotator cuff tears and they have no symptoms. It is well documented that the majority of major league baseball players have at least a type 1 SLAP tear and many have tears beyond this with NO symptoms.
With this in mind, are the pain syndromes we often see in clinical practice a result of structural or functional lesions? Obviously, the answer is “BOTH!” It is for this reason that a good history, exam and diagnosis that consider both structural and functional pathology are imperative.
Here is my recommended approach to managing structural and functional lesions of the shoulder:
- Remove offending activities (barbell bench press, overhead barbell bench press, upright rows, empty can raises, etc.)
- Soft tissue integrity and mobility of scapulothoracic, scapulohumeral, rotator cuff muscles and capsule. I use various methods of myofascial release, instrument assisted soft tissue therapy with and without movement, joint mobilizations and Mulligan Mobilization with Movement.
- Scapular stability and function and glenohumeral proprioception (consider thoracic and cervical spine function when doing this).
- Thoracic spine mobility/range of motion.
- Rotator cuff conditioning.
- Integrated scapulothoracic and glenohumeral stability, strength and functional movement patterns.
At this point the patients symptoms should have resolved and they should have pain free non sport-specific function. In other words, most if not all orthopedic maneuvers are negative or significantly improved and the patient can perform various functional movements while under load or with speed pain free. If after 6 weeks of treatment and rehabilitation you have not gotten here you should consider an alternative approach which may include surgery. I would have initiated the process of getting an MRI and orthopedic consult as soon as I had reasonable evidence to think there was a structural lesion, and depending on the patients circumstances (professional baseball player, young aspiring athlete, recreational athlete, non-athlete) fixing the structural lesion may be advisable regardless of rehabilitation outcome. If you have been successful in resolving their symptoms and signs then you should NOT stop there, move on to:
7. Kinetic chain function and rehabilitation (i.e. mobility of the opposite hip and ankle).
8. Core stability/force transfer.
NOTE: there is no reason why you wouldn’t initiate lower extremity and core training early in the rehabilitation process.
For a comprehensive course on rehabilitation of the shoulder check out the upcoming course with Dr. Buchberger in Calgary.
See related articles in my articles section under “upper extremity”.
Posted in the Upper Extremity Orthopedics article category
November 7th, 2008
Earlier this season, Josh Hamilton put on an amazing show with 28 homeruns in the first round of the MLB Homerun Derby. While he went on to lose to Justin Morneau in the finals of the contest, Hamilton did smash four 500+ ft. shots - and stole the hearts of a lot of New York fans. It’s an incredible story; Hamilton has bounced back from eight trips to rehabilitation for drugs and alcohol to get to where he is today.
Geek that I am, though, I spent much of the time focusing on the incredible hip rotation and power these guys display on every swing. According to previous research, the rotational position of the lead leg changes a ton from foot off to ball contact. After hitting a maximal external rotation of 28° during the foot off “coiling” that takes place, those hips go through some violent internal rotation as the front leg gets stiff to serve as a “block” over which crazy rotational velocities are applied. How crazy are we talking? How about 714°/s at the hips? This research on minor leaguers also showed that stride length averaged 85cm - or roughly 380% of hip width. So, you need some pretty crazy abduction and internal rotation range-of-motion (ROM) to stay healthy. And, of course, you need some awesome deceleration strength – and plenty of ROM in which to apply it – to finish like this…For a complete article with images please download this article in PDF format: Oblique Strains & Rotational Power
Posted in the Sports Injuries & Biomechanics article category
October 28th, 2008
Intervertebral disc height loss is considered by many as an indication of intervertebral hydraulic dysfunction. In scientific circles, decompression or unloading is a common theme in the pursuit of treatments associated with this loss and function. These interventions range from conservative to surgical treatments with varying success.
To date it is undisputed that lesions to intervertebral discs are intricately tied to pain syndromes–from annular tears to sequestered disc herniations. But understanding the realtime nature of intervertebral discs has been difficult to measure. Recumbent 3T MRI has played a significant power tool in the identification of diagnostic disc lesions and in turn, given us a snap-shot in time of possible reasons why patients may hurt in functional dynamic settings. The advent of upright MRI is becoming more useful as it able to image biological tissues under load but work is required to increase the power of the magnets to increase imaging resolution.
Click on the following link to read the full article: the-seated-anti-axial-creep-strategy-for-unloading-ivds-october-2008.pdf
Posted in the Spine Orthopedics article category
September 27th, 2008
A Balanced Diet Just Isn’t Enough
by John M Berardi, PhD, CSCS
What The Heck Is A Balanced Diet?
You hear it all the time - from your mom, from dietitians, from doctors, from coaches, heck, even from your uncle Jimmy.
Just eat a “balanced diet” and you should be fine.
Of course, the fact that no one ever mentions what actually constitutes a “balanced diet” only adds to the mystique and allure of this mythical creature.
To your mom, a balanced diet pretty much means whatever she puts on your plate. To your dietitian and doctor, it pretty much means to eat less saturated fat and cholesterol. To your coach, it means whatever keeps you from getting fatter. And to your uncle Jimmy, it means skipping breakfast, having fries and a burger for lunch, and having a 6-pack of Coors Light after work.
For most people, a balanced diet is simply a buzz word for “eating whatever I want to eat.” The phrase is beautifully vague enough to be able to justify their own personal choices with amazing vehemence and rationalization. It’s vague enough to convince folks that no changes are necessary in their daily intake. It’s vague enough for dietitians to suggest that no supplements are required to meet our daily needs.
Yet it’s also vague enough to be utterly useless and void of all utility or meaning. And it’s vague enough to ensure that the rates of diabetes and heart disease consistently increase.
Truth be told, as you’ve probably guessed by now, I hate the phrase “balanced diet.” Indeed, if there were one phrase that should be banned from our collective nutritional lexicon, this is the one. It’s a useless term that is often used to justify counterproductive habits.
How About A Dietary Analysis
To help illustrate my point, just the other day I was searching the medical databases for a host of diet analysis studies.
My goal was to find studies done on athletes, recreational exercisers, and sedentary folks.
And my intention was to find out whether or not their so-called “balanced diets” were actually providing them with the minimum level of nutritional intake established by the very conservative American Dietetics Association.
You see, the ADA establishes nutrition standards for the population at large.
For example, assuming a 2000kcal diet, the average person should be getting the following macronutrients each day, according to the ADA:
Total Fat 65 g
Saturated fatty acids 20 g
Cholesterol 300 mg
Sodium 2400 mg
Potassium 4700 mg
Total carbohydrate 300 g
Fiber 25 g
Protein 50 g
And in terms of micronutrients, here’s what we should be getting to achieve 100% of our recommended daily intake, according to the ADA.
Vitamin A 5000 IU
Vitamin C 60 mg
Calcium 1000 mg
Iron 18 mg
Vitamin D 400 IU
Vitamin E 30 IU
Vitamin K 80 μg
Thiamin 1.5 mg
Riboflavin 1.7 mg
Niacin 20 mg
Vitamin B6 2 mg
Folate 400 μg
Vitamin B12 6 μg
Biotin 300 μg
Pantothenic acid 10 mg
Phosphorus 1000 mg
Iodine 150 μg
Magnesium 400 mg
Zinc 15 mg
Selenium 70 μg
Copper 2 mg
Manganese 2 mg
Chromium 120 μg
Molybdenum 75 μg
Chloride 3400 mg
Again, these numbers are conservative. They’ve been established by the ADA as rock-bottom minimums required to prevent us from contracting nasty diseases.
They say nothing about optimization, mind you. However, they are still useful. After all, if we dip below these levels, we’re in nutritional deficiency land. Cue up pirate songs, eye patches, and the talk of scurvy.
So, in beginning the research review mentioned above, my goal was to uncover some of the published literature, to see if anyone ever actually achieves a “balanced diet” in the real world.
My criterion, of course, would be something measurable. I’d be using a real dietary analysis to determine just what “balanced” actually meant.
My Experience
Now, my experience told me that I’d be pretty disappointed in this notion of a so-called “balanced” diet.
When at the University of Western Ontario working on my PhD, I assisted Dr Peter Lemon with an advanced Exercise Nutrition course. And, as part of the class, every year we had 150-200 students do a personal dietary analysis.
So, for 3 years straight, it was my job to collect these analyses and plug them into a database for further review. And, over the course of 3 years, and over 500 exercise and nutrition students, it was my experience that very, very few of them achieved 100% of the recommended intake of all the macro- and micro-nutrients.
In general, only about 10-15% of them met all of their dietary needs. The other 85-90% were deficient in one or more key nutrients - whether it was zinc, magnesium, omega 3 fatty acids, or protein.
Interestingly, in my hunt above, I found an interesting study published in 2006. This study, published in the Journal of the International Society of Sports Nutrition, corroborated my experience perfectly.
Here’s what the researchers found.
Seventy diets were computer analyzed from the menu of athletes or sedentary subjects seeking to improve the quality of micronutrient intake from food choices. All of these dietary analyses fell short of the recommended 100% RDA micronutrient level from food alone.
In other words, over 70 diets were analyzed from individuals actively trying to improve their nutritional intake. And not a single one even achieved the minimum micronutrient suggested by the ADA!
The Study
If you’re interested in checking out the study details, which I think you should be, here’s the paper for your review.
J Int Soc Sports Nutr. 2006; 3(1): 51–55.
Food Alone May Not Provide Sufficient Micronutrients for Preventing Deficiency
Bill Misner
Introduction
Reference Daily Intakes (RDI) is a new term that replaces the familiar U.S. Recommended Daily Allowances (U.S. RDA). RDIs are based on a population-weighted average of the latest RDAs for vitamins and minerals for healthy Americans over 4 years old.
RDIs are not recommended optimal daily intake figures for any particular age group or sex. Government-established Reference Daily Intake guidelines (RDI) are designed to prevent nutrient-deficiency diseases.
Most nutritionally oriented professionals imply that a balanced variety of foods selected from the Food Guide Pyramid (FGP) will supply all micronutrients at the RDA or new RDI levels necessary to maintain optimal health and prevent nutrient-deficiency diseases. The American Dietetic Association (ADA) has proposed a conservative strategy for managing dietary micronutrient deficiency and sufficiency:
“It is the position of the American Dietetic Association (ADA) that the best nutritional strategy for promoting optimal health and reducing the risk of chronic disease is to wisely choose a wide variety of foods. Additional nutrients from fortified foods and/or supplements can help some people meet their nutritional needs as specified by science-based nutrition standards such as the Dietary Reference Intakes. This position paper addresses increasing the nutrient density of foods or diets through fortification or supplementation when diets fail to deliver consistently adequate amounts of vitamins and minerals.”
Between 1996 and 2005, 70 diets were computer analyzed from the menu of athletes or sedentary subjects seeking to improve the quality of micronutrient intake from food choices.
Surprisingly, all of these dietary analyses fell short of the recommended 100% RDA micronutrient level from food alone.
Therefore, based on diets analyzed for adequacy or inadequacy of macronutrients and micronutrients, a challenging question is proposed: “Does food selection alone provide 100% of the former RDA or newer RDI micronutrient recommended daily requirement?”
Methods
From 70 computer-generated dietary analyses, 20 subjects’ diets were selected based on the highest number of foods analyzed from 10 men (ages 25–50 y) and 10 women (ages 24–50 y).
A First Data Bank Nutritionist IV computer-program default was utilized, defaulted to apply the Harris-Benedict equation, a formula that determines energy expense against RDA micronutrient requirement, by age, gender, and body mass index (BMI).
The purpose of this study was to determine if food intake alone provided the Recommended Daily Allowances (RDA) requirements for 10 vitamins and 7 minerals. The ten vitamins analyzed were Vitamin A, Vitamin D, Vitamin E, Vitamin K, Vitamin B-1, Vitamin B-2, Vitamin B-3, Vitamin B-6, Vitamin B-12, and Folate. The seven minerals analyzed were Iodine, Potassium, Calcium, Magnesium, Phosphorus, Zinc, and Selenium.
The 20 Individual Diets analyzed originated from the following subjects:
1. Two professional cyclists athletes (A)
2. Three amateur cyclists athletes (A)
3. Three amateur triathletes athletes (A)
4. Five eco-challenge amateur athletes (A)
5. One amateur runner athlete (A)
6. Six sedentary non-athletes (S)
Hence, fourteen (14) athletes’ (A) and six (6) sedentary subjects’ (S) diets were analyzed for calorie and RDA-micronutrient adequacy or inadequacy.
Results
Based on each subject’s activity level (caloric expense), age, gender, and body mass index (BMI), 10 of the diets were found calorie-excessive, above energy requirements (4 men and 6 women), but the remaining 10 diets were found calorie-deficient, not meeting 100% of their energy requirements (6 men and 4 women).
When total calorie intake percents were averaged by gender, men consumed only 92.6% of the calories required for their total energy requirements, while women consumed only 97.3% of the calories required to meet their energy requirements.
Of the 20 diets analyzed, 50% were calorie-sufficient and 50% calorie-deficient resulting in an overall -7.4% deficiency for men and a -2.7% deficiency in women (Table 1.).
CLICK HERE FOR TABLE 1
Calorie deficient diets tended to record a greater number of micronutrient deficiencies as compared to the calorie-sufficient diets.
Of the 340 micronutrient entries generated from 17 micronutrients analyzed, all 20 subjects presented between 3 and 15 deficiencies each based on the Recommended Daily Allowances (RDA) value from food intake alone.
Males averaged deficiencies in 40% of the vitamins and 54.2% of the minerals required.
Females averaged deficiencies in 29% of the vitamins and 44.2% of the minerals Recommended Daily Allowances (RDA) required.
The male food intake was RDA-deficient in 78 out of 170 micronutrient entries, or 45.8% of the 10 vitamins and 7 minerals analyzed.
The female dietary intake was RDA-deficient in 60 out of 170 micronutrients or 35.2% of the 10 vitamins and 7 minerals analyzed. Both male and females as a single entity recorded 138 micronutrient deficiencies out of the possible 340 micronutrients analyzed, or 40.5% micronutrient RDA-deficiency from food intake alone. (Table 2.)
CLICK HERE FOR TABLE 2
Accuracy of the individual food-weighed measures, accuracy in reporting foods consumed, and the accuracy of the computer-generated software are factors that affect the accuracy of the results reported in this observational study.
The effect of activity on calorie deficiency in this contingent demonstrates an increased micronutrient deficiency in athletes (A) and surprisingly, the sedentary subjects (S) in this study also posted food-borne micronutrient deficiencies.
Each chronic deficiency proportionately increases the risk of nutrient-deficiency diseases. In highly active athletes (A), micronutrient deficiencies occur at higher rates because calorie deficits are associated with exercise expense.
Food alone in all 20 subjects did not meet the minimal Recommended Daily Allowances (RDA) micronutrient requirements for preventing nutrient-deficiency diseases. The more active the person, the greater the need to employ a variety of balanced micronutrient-enriched foods including micronutrient supplementation as a preventative protocol for preventing these observed deficiencies. (Tables 3, 4, 5).
CLICK HERE FOR TABLE 3
CLICK HERE FOR TABLE 4
CLICK HERE FOR TABLE 5
Concern for micronutrient adequacy from food alone is not a new question. Excerpts 70 years ago (1936) from the 2nd Session of the 74th USA Congressional Record (excerpts) stated:
“Laboratory tests prove that the fruits, the vegetables, the grains, the eggs and even the milk and the meats of today are not what they were a few generations ago (which doubtless explains how our forefathers thrived on a selection of foods that would starve us today).
It is bad news to learn from our leading authorities that 99% of the American people are deficient in these minerals, and that a marked deficiency in any one of the more important minerals actually results in disease. Any upset of the balance, any considerable lack of one or another element, however microscopic the body requirement may be, and we sicken, suffer, and shorten our lives.”
This twenty-subject dietary analysis study is not representative of the entire population, however the results supported by the 1936 congressional record, beg the question:
“Does food selection alone provide 100% of the former RDA or newer RDI micronutrient recommended daily requirement?”
It may be that chronic micronutrient insufficiency from food alone is more fact than fantasy. This study calls for a dietary analysis of a larger contingent of the population to determine if there is an association between chronic suboptimal RDI-micronutrient deficiency and suboptimal health disorders that may digress into disease.
Our Conclusions
In the end, the take home message here is quite clear.
Most people trying their best to achieve a “balanced diet” are falling short, creating personal deficiencies in vitamins, minerals, and more.
In the study above, the nutrients folks were most at risk for deficiency in were:
Iodine - 100% of the diets were deficient in iodine
Vitamin D - 95% of the diets were deficient in vitamin D
Zinc - 80% of the diets were deficient in zinc
Vitamin E - 65% of the diets were deficient in vitamin E
Calories - 50% of the diets were deficient in calories
Calcium - 50% of the diets were deficient in calcium
Of course, this doesn’t mean that nutritional supplements are necessary as a first line of defense. Indeed, recent data have clearly demonstrated that the vitamins, minerals, and phytochemicals found in real food, dose per dose, often outperform those found in pills and capsules.
What it does mean, however, is that if you’re not getting the advice of a nutrition professional, or if you’re not following a sound eating protocol that’s designed specifically to overcome nutrient deficiencies, you’d better get cracking.
The longer you wait, the more at risk you’ll become for a host of nutritional deficiency related diseases and disorders, diseases and disorders you could have prevented simply by changing just a few eating habits.
For more great training and nutrition wisdom, check out Precision Nutrition. Containing system manuals, gourmet cookbook, digital audio/video library, online membership, and more, Precision Nutrition will teach you everything you need to know to get the body you want — guaranteed.
Posted in the Nutrition article category
July 10th, 2008
This months newsletter article features a PhD thesis out of the Institute of Sports Medicine Copenhagen. This thesis effectively summarizes the current literature on the structural and mechanical properties of achilles and patellar tendonopathy, including pathology and treatment options. I considered doing a review on this but there is just too much good information I didn’t want to skip over…so you are getting it in full…enjoy!
Please follow this link to the article - “Structural & Mechanical Adaptations of Tendinous Tissue - effects of exercise, loading and injury”
Posted in the Lower Extremity Orthopedics article category
June 19th, 2008
This study tests Brian Mulligan’s proposition that mobilization with movement 1) reduces pain and improves function in patients with lateral epicondylalgia and 2) that mobilization with movement is capable of inducing physiological effects similar to those reported with some forms of spinal manipulation.
Somatic Senses Newsletter - Nov 07
Posted in the Upper Extremity Orthopedics article category
June 18th, 2008
This is an outstanding article written by Alex Vasquez, DC, ND, Gilbert Manso, MD, and John Cannell, MD.
The OBJECTIVES of this article are:
1. Appreciate and identify the manifold clinical presentations and consequences of vitamin D deficiency
2. Identify patient groups that are predisposed to vitamin D hypersensitivity
3. Know how to implement vitamin D supplementation in proper doses and with appropriate laboratory monitoring
THE CLINICAL IMPORTANCE OF VITAMIN D: A Paradigm Shift with Implications for All HealthCare Professionals
Posted in the Nutrition article category
June 18th, 2008
Posted in the Spine Orthopedics article category
January 23rd, 2008
Somatic Senses Newsletter - Removing the myth of TMJ conditions
For many years, TMJ or jaw-related patients have been placed in the category of mysterious, non-responsive conditions that are very difficult to treat. Fortunately evidence is beginning to sprout that identifies these problems as musculoskeletal conditions like those in other parts of the body. Most importantly, if they are diagnosed properly and treated with an active care approach, these conditions can recover with minimal chronicity.
Posted in the Spine Orthopedics article category
September 25th, 2007
The SomaticSenses.com October 2007 newsletter article features a research review provided by Dr. Shawn Thistle and his Research Review Service. This study comes from Stu McGill’s lab at the University of Waterloo titled “Quantification of lumbar stability by using 2 different abdominal activation strategies“. This review covers the commonly debated topic of abdominal activation strategies and their relation to lumbar spine stabilization. Although one must consider all sources, I believe this review sheds good light on the topic and has strong potential to enhance your rehabilitation and/or performance training strategy.
SomaticSenses.com October 2007 Newsletter
Posted in the Spine Orthopedics article category
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