Take Your Core and Rotator Cuff Exercises to the Next Level
Here are a couple great ideas to take your rotator cuff strengthening and core stability exercises to the next level around the Christmas tree this season.
Vitamins -To Take or Not To Take?
Do you take a multi-vitamin? Do you take vitamin C? If you said yes, you wouldn’t be alone. Supplement sales in 2012 hit $11.5 billion and are projected to be over $15 billion by 2017. People are looking for alternatives to traditional medicine and pharmaceuticals. If you have been in my physical therapy clinic, I am sure that many of you have heard me say “I am trying to place your body in the best position to heal”. The same can be said for my thoughts on vitamin and mineral supplements. Our bodies are incredible healing machines if you simply provide it the proper environment and the proper sustenance in which to heal. This blog post has been a labor of love as it has taken over 6 months to complete. I have attempted to provide THE EVIDENCE for why and what we should take for supplements. I hope this helps! Let me know what you think.
The first thing you need to realize is that there are a lot of unsubstantiated health claims made about vitamin and mineral supplements. You have to be a careful observer when reading about the “health effects” of supplements. Most of these substances are unregulated by the FDA. There has been an advocacy movement on the part of the USFDA to protect the consumer from unsubstantiated health claims. You can read more HERE. You need to be the educated consumer before making a purchase. Websites such as www.multivitaminguide.org provides a scientific comparison of over 100 brands of multi-vitamins. Check it out and see how YOUR choice compares.
I am of the opinion that you have to base your decision regarding supplements on the best available scientific information. This may mean that you put more trust in the biological “process” than in the actual “claim”. For example, we know that free radical damage is a “process” that can be mitigated by antioxidants. However, we cannot claim that antioxidants will “prevent cancer”. Read HERE to see four scientific examples or do a Medline search for the “effects of antioxidants” and take your pick.
I think that all of you would agree that stress is a threat to a person’s well-being. Your body responds to stress by utilizing an elaborate system of enzymes, vitamins, minerals and antioxidants to defend itself. Read HERE for details. An antioxidant is a compound that neutralizes the effects of free radicals. Free radicals are highly unstable molecules that attack the nearest stable molecule and strip it of an electron. This can cause a chain reaction called oxidative stress which can cause damage to a living cell. Free radicals are a natural byproduct of cellular metabolism but their numbers may exceed the number of antioxidants when experiencing high levels of emotional OR physical stress. If this cycle goes unabated, it may lead to inflammation, infection, heart disease, or cancer to name a few. Obviously, this is a process that we want to mitigate. As a result of the depletion of antioxidants when under stress, it is recommended that you supplement or ingest fruit & vegetables not just once, but several times during the day. Yes, there are many different types of antioxidants. Vitamin E & C are probably the most popular. What do you choose as part of a dietary supplement regimen? It depends on who or what you read and how much money you want to spend. Is one any better than the other? Same answer! One way to look at it is “the more you stress, the more you need”.
The recommended daily allowance of fruits and vegetables to maximize your levels of dietary antioxidants is 5-10 servings. Rich Vitamin E sources are things such as whole grain, nuts (especially almonds!), and seeds. Read more HERE. Unfortunately, most people don’t come close to these daily allowances. One way to help neutralize the effects of free radicals is to supplement your diet with antioxidants. Vitamin E is a fat-soluble antioxidant that is very efficient at breaking the oxidative stress chain. Vitamin C is a very abundant water-soluble antioxidant. It actually plays a role in returning Vitamin E to its active form. All citrus fruits contain high levels of Vitamin C. Polyphenols are another option. They are the chemicals that give fruit and vegetables their color. They are powerful antioxidants as well. Here is one example of polyphenols and one that I take on a daily basis. Check it out HERE.
So what’s up with the fatty acids? I’m sure that you have heard of omega-3’s and omega- 6’s. Right? This is the reason some people take “fish oil”. Some of you may even remember choking down cod liver oil as a child. With the advent of preservatives and the addition of poor quality vegetable oils in our foods, our ratio of omega-6 to omega-3 has gone awry. The ratio of omega-6 to omega-3 in the typical Western diet can be up to 16:1. Not good! Human beings evolved with the ratio being around 1:1. Excessive amounts of omega-6 polyunsaturated fatty acids and a very high omega-6/omega-3 ratio can promote diseases such as cancer, cardiovascular disease and inflammatory and autoimmune diseases, whereas increased levels of omega-3 (a low omega-6/omega-3 ratio) can have a preventative effect. Omega-3 can also help regulate pain and inflammation as well as maintain proper blood pressure and cholesterol levels. Read HERE for more.
So how do you decide which omega product to purchase? You want to purchase a product that has the highest purity and potency. Purity means that it is free of toxic chemicals such as mercury and PCB’s. Potency is based on the actual amount of EPA and DHA in the oil. EPA and DHA are the essential fatty acids in omega-3. Essential fatty acids cannot be produced by the body and are “essential” to ingest. Food sources high in omega-3 are salmon, almonds, flax, walnuts just to name a few. Check on-line for a chart. You want to ensure that the product that you intend on purchasing has undergone third party testing. The International Fish Oil Standards Program at http://www.ifosprogram.com/ is one such organization. Here is an example of the IFOS page for the omega 3 product that I use. Click HERE. So how much omega-3 do you need? I have concluded based upon my research that the daily recommended allowance for omega-3’s is anywhere between 2500-10,000 mg.
Have you ever had your Vitamin D level checked? If not, you may want to. A study published in the Archive of Internal Medicine in 2009 showed that Vitamin D levels have “plummeted” among ALL U.S. ages, races, and ethnic groups over the past two decades. This is especially true in seasonal parts of the country like New England where sun exposure is variable. Because there are such small amounts of Vitamin D in food, the only 2 ways to get adequate amounts is thru direct sun exposure or via supplements. The best form to take is Vitamin D3 and it is this form that is produced during sun exposure. Over the past 10 years, several researchers have found an association between extremely low vitamin D levels and chronic, general pain that doesn’t respond to treatment. Read HERE. Go the preceding link to read several examples of people who had miraculous results in pain reduction with Vitamin D supplementation. So how much should you take? The Vitamin D council recommends anywhere between 5000-10,000 IU per day. Check out their recommendations HERE. Here is a LINK comparing options for purchasing vitamin D. I take the generic Vit D3 from CVS.
So how about the MANY other vitamins and minerals? The Vitamin D Council gives recommendations for vitamins that work synergistically with Vitamin D. They include Vitamin A, Vitamin K, Zinc, Boron and Magnesium. You can read more about them and the recommended daily allowances HERE. As mentioned earlier, websites such as www.multivitaminguide.org provides a scientific comparison of over 100 brands of multi-vitamins which should contain all the recommended daily allowances of trace minerals and vitamins. My choice is first on the list from XtendLife: Total Balance. If you need to supplement your B vitamins, another option in liquid form is called Folidreen. Taking your supplements in liquid form and adding them to juice is a great option for those who have difficulty taking pills.
I have also been questioned about and have had personal experience with urine turning a bright yellow when taking a multivitamin. Is this bad? One of the main reasons for this is the excretion of riboflavin. The Latin origin of riboflavin is from the word flavus which means “yellow” or “blonde”. Your yellow urine reveals one key thing. Your body has taken what it can from the vitamins and the rest is excreted. Read more HERE.
So why do we need trace minerals? Minerals are essentially the elements on the periodic table in chemistry class. They are things like chromium, zinc, magnesium, calcium, iron etc. They work synergistically with all of the other vitamins and nutrients that our bodies need to maintain optimal health. Ideally, trace minerals should come from eating a raw food diet. Unfortunately, researchers have shown that raw food isn’t even enough because our soils have been so depleted of these vital minerals. It is believed that 90% of people are deficient in trace minerals. READ HERE. If it’s not in the soil and it’s not in our food, then what do you do? You need to get your trace minerals via a supplement. You need to scrutinize your multi-vitamin and even look into liquid options such as Concentrace: Trace Mineral Drops.
Another example of the importance of minerals is the balance of calcium and magnesium in our systems. As stated at Natural Vitality:
“Magnesium and calcium are fundamental nutrients that need to be in balance with each other in order for you to fully experience good health. Their importance on a cellular level is critical. Calcium and magnesium are like opposite sides of a coin. Calcium excites nerves, while magnesium calms them down. Calcium makes muscles contract. Magnesium is necessary for muscles to relax. Calcium is needed for blood clotting, but magnesium keeps the blood flowing freely.”
Deficiency of magnesium or calcium can be caused by a number of stresses on the body including emotional stress, taking drugs such as diuretics, antibiotics, oral contraceptives, insulin, or cortisone, heavy exercise, diabetes, and gastrointestinal disorders. Some people may need to seriously consider supplementation when these conditions exist. Calcium is extremely important as an alkalizing agent for your body. Stress and poor nutrition makes your body acidic. Acidic environments promote cancer growth! The recommended daily intake of calcium according to the National Institute of Health is 1000mg for adults aged 19-50 and 1200 for 51 plus. The recommended daily intake for magnesium according to the NIH is 320g for age 30 and older. Don’t forget that calcium CANNOT be ingested without Vitamin D. So you may want to order the combination of the two in a product. An excellent source of calcium is coral calcium. You can read HERE for a comparison of the best coral calcium products on the market. I order mine in tablet and powder form (for my smoothies) from True Blue.
So how about your joints? What are the best supplements? You want to focus on products that deliver RESULTS! The best known supplements for joint health are glucosamine and chondroitin. But have they been shown to be effective? The Cochrane Database www.cochrane.org of Systemic Review is the largest collection of randomized controlled studies in the world. The Cochrane Review of glucosamine for arthritis looked at 4963 patients and concluded that glucosamine “failed to show benefit in pain and function”.
Products which contain esterified fatty acids are turning out to be the new gold standard in the treatment of joint pain. One example is EFAC or esterified fatty acids complex. It is comprised of a proprietary blend of esterified fatty acids that inhibit the inflammatory cascade by bonding to white blood cells and inhibiting a mediator of inflammation called prostaglandin. Double-blind studies using EFAC for osteoarthritis and periodontal (gum) disease have been published in leading medical journals including the Journal of Rheumatology and the Journal of Periodontology. It has been shown that EFAC can reduce joint and muscular discomfort within 30 minutes of topical application and within 14 days of oral consumption. You can read more HERE.
It is available in both capsules and creams in order to maximize your results. Both are available and for sale in our clinic. You can find more information at www.hopescience.com.
In conclusion, yes, I am a believer in taking supplements. I hope that this blog post has made you a believer as well. Please let me know your thoughts or your experiences with supplements. We can all learn from one another!
Are Rotator Cuff Tears Inevitable?
Factors For Success With Your Rotator Cuff Repair
As our society stays more active into our later years, shoulder rotator cuff tears are becoming more prevalent. 13% of persons over the age of 50 and 50% of persons over the age of 80 will experience a rotator cuff tear (RCT). 1/3 of these tears will present as pain, loss of ROM, or decrease in function. If conservative measures fail, surgery may be your only option. The study below looked at positive patient outcomes with surgery and the demographics leading into it. Some factors that the patient can control included higher bone mineral density, increased higher level of sport activity and the absence of obesity. If you are preparing yourself for RCT surgery, talk to your PT or PCP on how you can manage your health to set you up for success. CLICK HERE for article.
Baseball Throwing Injuries. Oh no…not me!!!
Throwing a baseball is the fastest known human movement. The speed of the throw from a professional baseball pitcher can be upwards of 7000 degrees per second. Now that’s fast! In addition to that, the shoulder is the most mobile joint in the human body. So what does this mean?
EXCESSIVE SPEED + EXCESSIVE MOBILITY = POTENTIAL PROBLEMS
Image courtesy of FreeDigitalPhotos.net
For those of you that “feel a need for speed”, you need to beware of the risks. In an article from the Journal of Sports Medicine, twenty-three professional pitchers were followed over three seasons. Those pitchers who were throwing at the highest maximum velocity suffered the highest incidence of elbow injuries. So how does that effect you? It is vitally important for the throwing athlete to understand the stresses that repetitive throwing places on young as well as mature joints. In the words of baseball trainer phenom Eric Cressey, “injuries occur when you ignore the things that need to be addressed, plain and simple.” In one of my previous blog posts, I talk about how it has been scientifically proven that strength training enhances athletic performance. Shoulders and elbows become problematic not only because of muscular weakness, but also from poor flexibility, poor tissue quality ie scar tissue and, of course, faulty mechanics.
For example, consider the dreaded inverted or upside down “W” exhibited by the Yankees’ Joba Chamberlain or the National’s Stephen Strasburg.
Guess what happened to them? Yup….Tommy John surgery to fix a torn ligament in their elbows. So then…
EXCESSIVE SPEED + EXCESSIVE MOBILTY + BAD TECHNIQUE = DEFINITE PROBLEMS
Just because a joint is flexible does NOT mean that it is stable. Consider the six phases of throwing and all the potential areas of instability when throwing at maximum velocity. Our objective should be to achieve dynamic stability during ALL phases. Yes, if you are stiff we are going to stretch you and if you are loose we are going to stabilize you…but what about the gray areas? Every major league pitcher suffers from a loss of shoulder internal rotation for at least 3 days after an outing. This is a situation when you do NOT stretch. The resulting loss of motion is due to the micro-trauma of eccentric load during deceleration and needs time to heal. It has been shown that the posterior aspect (the back part) of the shoulder joint capsule actually thins out after repetitive throwing. So let me ask you, should we ever stretch the posterior aspect of the shoulder joint? Or should treatment focus more on the scar tissue that results in the decelerators?
So what are the most common upper extremity baseball throwing injuries? These injuries include the problems associated with overuse or improper training such as:
• Impingement syndrome
• Rotator cuff tendonitis
• Biceps tendonitis
• Medial elbow pain from flexor-pronator tendonitis
These overuse injuries can lead to more serious conditions such as:
• Rotator cuff tears
• Labral tears
• Ulnar collateral ligament (UCL) tears
We have many manual tests that we can perform in the clinic to differentiate and determine what structures may be involved in YOUR specific case. In the case of impingement syndrome, I have previously posted a BLOG article on the different types of impingement syndrome as well as a VIDEO demonstrating the tests that we use to differentiate rotator cuff versus labral dysfunction. It should be noted that a condition called scapular dyskinesis can lead to impingement syndrome. This condition is characterized by an imbalance of scapular motion relative to shoulder motion. It is the result of weakness in the muscles that stabilize the scapula during the throwing motion. I have also listed some of the best, evidence-based exercises in a previous post for specific shoulder and scapular retraining.
It is very important for your therapist to differentiate between what we call active restraint or passive restraint structures. Active restraint structures are those things that contract and relax like your muscles and tendons. Passive restraint structures are things like ligaments ie UCL, cartilage ie labrum and meniscus, and discs ie intervertebral discs. I would like to highlight the UCL of the elbow as one example of this. For many pitchers, the first sign of impending trouble with the UCL is pain or stiffness in the flexors of the forearm. The flexors and pronators of the forearm are the active restraints and the UCL is the primary passive restraint to the extreme valgus forces that occur at the elbow during terminal cocking phase and early acceleration. Did you know that when the UCL is tested in isolation during cadaver studies that it only takes 32 newton/meters of force to rupture it? Guess how much valgus stress is on the inside part of the elbow during terminal cocking phase….64 newton/meters!! It has been shown that the UCL takes on 35 newton/meters of that force. Yikes!! So why doesn’t it rupture? It doesn’t rupture because the rest of that stress is controlled by the active restraints…your muscles in the forearm. You can probably guess what happens when you ignore your forearm muscles?
As mentioned earlier, imbalances in flexibility, tissue quality, biomechanics, or weakness can lead to stress on both active and passive restraints during the throwing motion. Invariably, the process of repetitive throwing leads to the development of scar tissue. There is a constant state of break-down and build-up that occurs during sport specific activity. I have blogged on problems with scar tissue and the debate on whether pain arises from tendonitis or not. I have also explained the benefits of the Graston Technique as a way to ensure that scar tissue does NOT inhibit your ability to throw.
Now, what blog post is complete without a little twist. After listing the most common injuries that we see in the throwing athlete, I would like to share a list of conditions that have been confirmed via MRI in athletes that have NO pain:
* 79% of overhead throwing athletes have labral tears
* 34% of athletes have rotator cuff tears
* 82% of athletes have disc herniations
Does this mean that you may ALREADY have a tear and that you are currently asymptomatic like the athletes in the previous studies? Yes, you may. Does this mean that your future hall of fame career is over? No, it doesn’t. Some practitioners are of the opinion that you may very well need a labral lesion to throw hard in the first place. The biggest challenge with this is ensuring that the throwing athlete develops all the things that we have talked about in this post:
• Dynamic stability
• Proper flexibility
• Maximum strength
• Proper tissue quality
• Proper throwing mechanics
It is ALL these reasons that make it vitally important to be as educated as you can about your shoulder mechanics and to be aware of the important role that training and physical therapy play in keeping you healthy. It is our role as your physical therapist and performance specialist to guide you with you in this process. Here is an example of an effective warm up program for baseball players by the former trainer for the Boston Red Sox, Mike Reinold,PT. CLICK HERE.
Understanding throwing biomechanics in combination with a thorough knowledge of the anatomy and function of the shoulder and elbow is imperative to properly diagnose and treat the throwing athlete. Your prognosis for a healthy return to competition after arthroscopic surgery or ligament reconstruction has dramatically improved especially when you are in the right hands during recovery. My job as a physical therapist is not only to effectively rehabilitate your body after surgery but, more importantly, to help PREVENT the need for surgery in the first place. Of course, this is a two way street. I can only be your coach if you are a willing and motivated player.