What does "Use Pain as your Guide" really mean??

Patients are often told by their physiotherapist, surgeon, or sports medicine doctor to "use pain as your guide" in recovering from an injury, but what does that really mean? Will you get better results if you push through more pain or should you stick to no pain at all? The answer to this is usually somewhere in the middle. When rehabilitating from an acute injury such as a fracture or surgery, you need to push through a bit of pain to get the gains in range of motion and strength you need, however if you push too hard you can create inflammation, which may lead to more scar tissue formation, or worse reinjure yourself.

Here are the guidelines I often use (and these may be different for your health care professional, so make sure to ask!):

1. Distinguish between the stretch or muscle fatigue sensations and a pain sensation. Stretch and muscular work are OK
2. Don't let the exercise increase your pain by more than a 2/10. In some cases you may want NO increase in pain with the activity (for example nerve pain should be non-existent with an activity since nerves are so sensitive)
3. Does the increase in pain last for more than 30 minutes after your rehabilitation exercises or activity? Or do you get a rebound effect where it feels the same or better initially, but your pain increases two hours or longer after an activity? If so, it was probably too much!
4. Most importantly when you look at the big picture is your injury improving, static or worsening? If it is one of the latter two, it is time to revisit your exercises and activity program!

In conclusion "use pain as your guide" does not mean you should have total rest, but modify activity within limits. Stretching and strengthening even if the exercises feel "lame" will help you heal and get back to your normal activities faster!!!

Image courtesy of Google Images.

Top 5 Worst Gym Exercises

I recently polled all the physios, chiros and trainers who were friends of mine to see what they found as the worst offenders for causing or contributing to injury (needless to say this article is based on absolutely no scientific evidence). I got some great answers, including dropping a weight on your foot! In general, however, it seemed to be the consensus that it was usually overtraining, poor preparation or poor posture that were the causes of most injuries as opposed to specific exercises.

With that caveat in mind, here were the top 5 worst gym exercises:

5. kettle bells - if weak, will strain your back or intercostals
4. anything behind the head (pull downs or presses) - who does that anymore??
3. bench press - requires great rotator cuff stabilization - trouble if they are weak
2. upright rows - hello shoulder impingement

And with near perfect agreement, the worst offender for causing (most likely worsening) injury, the number one worst gym exercise is...

1. knee extension machine - lets add patellar compression to a knee that has patellar femoral pain!


picture courtesy of google images

Could Sitting be the Cause of my Sports Injury?

I have long maintained in my practice that no matter how well you set up your work station, humans are just not meant to sit for prolonged periods. There is a wonderful TED talk on the dangers of sitting. It highlights all sorts of negative effects of sitting.
One aspect the talk did not touch on was how, for all you weekend warriors out there, it can contribute to sports injuries too!!! I see many patients who, despite their active lifestyles, end up with injuries that are partially related to spending the majority of their day sitting at a desk or in a car.

One structure prolonged sitting puts strain on is the intervertebral disc. Over time sitting can lead to a weakening of the outer fibrous layers or annular fibers of the disc. Then if you participate in an activity where there is lots of forward bending, such as volleyball or hockey goaltending, putting further strain on the disc, you may end up with a herniated disc. In addition, because these annular fibers are angled, sports with forceful unidirectional twisting such as golf or softball may also lead to herniation when the disc is in this weakened state.

Prolonged sitting also leads to muscle imbalances which can in turn contribute to injury. Hip flexor tightness can lead to ITB friction syndrome, tight pecs and weak scapular muscles can lead to rotator cuff impingement, tight hamstrings can lead to hamstring tendon issues... you get the idea.


So what can you do about it? Its not like you are going to quit your job. Here are a few hints to try to minimize the negative effects of sitting:

• get up and walk as often as you can during your work day
• try not to adopt poor posture while you are sitting (see the picture above!!)
• try to pick activities that are not in the sitting position after sitting all day- or modify so that you aren't sitting as much - for example walk the course instead of sitting in a cart, pick an upright bicycle instead of leaning forward
• keep yourself fit outside of your sport participation - stretching and strengthening will help keep you in the game!

I hope these tips help you keep your active lifestyle for as long as possible.

Pictures courtesy of Google Images

The 5 W's of Stretching

I am asked about stretching in the clinic at least once a week, so I thought a blog about stretching would be pertinent. Here are the Who, What, When, Where, Why, and even How of stretching:


WHO?
Everyone! Whether prescribed by your physiotherapist for rehabilitation, as an injury prevention strategy or simply to delay the loss of range of motion associated with aging, everyone should stretch!!

WHY?
Stretching can have two main goals. The first is to prepare for the upcoming activity (and to reduce injury in that activity). The second is to try to increase tissue length to maintain or restore the health of the muscle or joint in question.

WHAT?
The goal of the stretch will determine the type of stretching you do.
Pre-activity or preparative stretching will be dynamic in nature.
Static stretching (stretches which are held for 30s-1minute) are done with the goal of increasing tissue length.

WHEN?
Dynamic stretching should be done before activity. Static stretches pre-exercise not only have no affect on injury prevention but may actually diminish performance.
Static stretches can be done any time (other than pre-activity) but will be more effective when you body temperature is elevated - after exercise, light activity or even a hot-tub.

WHERE?
Anywhere!!

HOW?
Dynamic stretches could include leg swings, dynamic trunk twists etc. Dynamic stretching should be progressive in intensity and be related to or mimic the upcoming activity.
Static stretches should be held for at least 30 seconds (or over a minute according to some studies) to effectively achieve gains in range of motion.



Pictures courtesy of google images

What is an Eccentric Exercise, and Why Does My Physiotherapist Keep Giving them to Me??

An eccentric strengthening exercise, sometimes referred to as a negative, is defined as an exercise where the muscle is lengthening under a load. This is most often the lowering portion of the exercise. People working on strength training will sometimes use eccentric exercises with a weight that is currently too heavy for the entire exercise to push past a plateau.

Physiotherapists prescribe eccentric exercises to promote healing of tendons and tendon insertions. In fact eccentric strengthening is far and away the most supported treatment for tendon repair. Eccentric exercises were first shown to be effective in a 1998 Swedish study on Achilles tendinopathy, and is now the gold standard for treatment as its efficacy has been repeated in a number of other studies since. The exercise protocol used in the original study included the lowering portion of a calf raise being done on one foot and the raising done by both legs. 10-15 repetitions of the exercise were performed twice a day, over a step and even if there was pain involved (unless it was debilitating). They were also done in both the straight leg (B) as well as the bent leg positions (C). It was a twelve week program. Weight was added to the exercises when the exercises were completely pain free. The results were remarkable as 100% of the subjects assigned to the eccentric program were able to return to pre-injury activity levels at the end of the program and their pain as measured by visual analogue scale (VAS) decreased from 81.2 to 4.8 (± 6.5) out of 100!

The exact mechanism of eccentric strengthening has yet to be elucidated but it has been shown that these exercises improve the quality of tendon structure.

Examples of using this type of exercise for other types of tendon or insertional tendinopathies are as follows:

• Patellar tendon: leg press pushing with two legs, and lowering with one
• Lateral epicondylitis (tennis elbow): wrist extensions with a small weight (2lb to start)- using the good hand to lift the weight and the bad hand to slowly lower.
• Medial epicondylitis (golfer's elbow): as above but wrist curl
• Biceps tendinopathy; biceps curl using small weight lifting your bad forearm up with the good one and then slowly lowering with the bad arm

You get the idea.

So now you know why eccentric exercises are pushed by your physiotherapist... and why you should do them!!

Photo courtesy of Google Images

Tips for Minimizing Back Injuries in Golf

As the weather gets nicer and the ground dries up, many people are itching to get out on the golf course. It is a great activity, but golf is a sport that places tremendous forces on the back. With our sedentary lifestyles, we have already created weakness in our backs; so if you sit all day in an office and use golf as your only activity... you are creating the perfect storm for back injury!


Here are a few easy tips to minimize (although certainly not erase!) the strain on your back during your golf game:

• Stretch your hips out regularly: tight hips transfer rotational force into your back.
• Address the ball with knees slightly bent and feet slightly turned out. This will transfer some of the strain to your legs
• Push your clubs rather than pull them. When using a hand held cart, pulling it behind you creates a constant rotational force through the spine. Pushing the cart removes that extra strain on the back
• If you insist on carrying your clubs, use a lightweight, double shoulder strap (back-pack style) type of bag rather than one that crosses the chest and limit the number of extra objects that aren't typically used that are carried in the bag.
• If you use a motorized golf cart, try to stick to the smoothest path as hitting bumps will create a compression force on the backs.
• One last very simple thing to do to decrease back strain in your golf game is to pick up the ball either by kicking one leg out behind you, squatting down or using a ball retriever.

There are other more technical ways to decrease the forces placed on your back during your golf swing, but they are too difficult to get into here. Hopefully these tips will help and best of luck with the upcoming golf season!!

Pictures courtesy of Google Images.

Top 8 Running Shoe Myths

As you may be heading out to purchase running shoes for the upcoming running season, I thought I would try to bust the following myths about running shoes and their ability to reduce injury.

1. Bigger people should wear bigger, bulkier shoes. Individuals with a higher BMI (body mass index) are more susceptible to injury regardless of what level of cushioning is in their shoe. 
2. A shoe’s cushioning decreases the shock to the runner’s body. There are many studies that show that the cushioning in modern shoes does not decrease the stress on the bones; and in some studies it has been shown to increase it, possibly due to the significant changes they cause in the running gait. The one place that shoes can reduce stress is in the foot, so if you have foot injuries, the choice of running shoe may help.
3. Cushioning shoes decrease injury. A very recent study  shows that there is no correlation with the type of cushioning in a shoe and injury prevalence.
4. Minimalist shoes decrease injury. See above and below!
5. Minimalist shoes will increase the strength of the intrinsic muscles of the foot. Look up any information on the Vibram 5 finger law suit to see where that claim got them!
6. Rigid or motion control running shoes can correct “abnormal” biomechanics. Biomechanical studies show that medial support used to “correct” pronation does not actually reduce the amount of pronation from barefoot running… it only corrects the pronation inherently CAUSED by the cushioning of the running shoe itself!! 
7. Getting your running shoe “fit” at a running shoe store will reduce injuries. One study suggests that doing so is just “not evidence based”
8. Paying more for running shoes means you have better shoes. The huge running shoe industry is constantly trying to tell us that their model superior to their competitor’s or even their last year’s model, but there is just no scientific evidence to back it up.

In summary most evidence suggests that the running shoe you select has no impact on injury incidence. However, keep in mind the most recent study is a prospective study, lumping all injuries together, so running shoe selection may have an effect on your specific injury or your body. So pick a shoe YOU are comfortable with in fit, cost and appearance!!!  

Photos courtesy of Google Images.