Friday, May 29, 2009

Basketball and Knee Pain

Jumping out of the Gym

Leaping ability is a quality that has categorized basketball players since Dr. James Naismith invented the game in 1891. How high a player can jump has a significant impact in determining their potential, or better yet, their careers. Think about it! How often do we focus on the number of inches between the court and the players’ sneakers? It seems as though we are now more amazed by an athlete's ability to jump, rather than the skills he or she may possess.

Every year in March, it seems we are discussing the average skilled NCAA athlete with a leaping ability that is through the roof, so to speak. Over the past few years, there have been multiple players referenced, most notably Joe Alexander from West Virginia, Corey Brewer from Florida and Tyrus Thomas from LSU. These players were prime examples of average skilled athletes with tremendous leaping ability. And what happened to them? Well, they’re in the NBA of course! That being said, more focus should be placed on the health and well being of a crucial part of the leaping ability; the knees.

Patellar tendonitis, commonly referred to as Jumper’s Knee, is one of the most popular conditions that can hinder, sideline, or even force a player to end his or her career. This condition is a repetitive stress injury of the patellar tendon (the tendon that connects the knee to the shin) and gets its name from, you guessed it, jumping too much! The symptoms can vary in degree, and are characterized as pain and tenderness just below the knee cap, or patella. With a condition so simple, it seems as though treatment would be the same. However, it’s not.

The suffix of the condition, patellar tendonitis, implies that it’s an inflammatory condition. This traditionally calls for treatment including rest, ice, anti-inflammatory medications, therapeutic ultrasound, all directed towards reducing inflammation. However, the condition is actually a tendonosis, which suggests that there is a dysfunction within the tendon, and actually no inflammation at all. This completely changes the treatment protocol.

Jumper’s knee, which should be known as patellar tendonosis, is actually a degeneration of the patellar tendon which leads to eventual fibrosis and adhesion formation within the tissue. This condition is still believed to be caused by repetitive stress of the patellar tendon. However, it is suggested that the tendon dysfunction is accompanied by aberrant motion of the patella as well. Therefore, rather than focusing on reducing inflammation, the appropriate treatment should be to address the function of the patellar tendon and joints of the knee.

Initial treatment should include heat and electric muscle stimulation to allow an increase of blood flow to the affected area, and help promote tissue healing. Soft tissue therapy, such as the Graston Technique, is beneficial in reducing the amount of fibrosis and adhesions within the patellar tendon. Also, manipulation of the patellofemoral (knee) joint may be necessary to assure the joint is functioning properly. These initial steps will help address the tendon dysfunction, as well as aid in pain control.

Further treatment may include Kinesio Tape on or around the patella to help re-educate the knee musculature into proper biomechanics. This is followed by rehabilitation of the knee, which includes multiple stretching and strengthening exercises. The idea is to educate the knee musculature to work properly, and then to strengthen the affected muscles in order to avoid future injury. Treatment frequencies and length of treatment may vary based upon the severity of the condition. This is why it is very important to recognize the early symptoms, and get treated to avoid future complications.

The ability to jump has become one of the most important factors in determining an athlete’s future. In many ways it has surpassed the importance of the fundamentals of basketball as we know them today. Therefore, in addition to the many shooting drills, sprints, and defensive slides done on a daily basis, early recognition of sub patellar knee pain should be practiced as well. After all, it just might help you make your career!

Wednesday, May 27, 2009

Cycling and Back Pain Part II

Ok, so your back hurts and you want to know what to do. First off, you CANNOT ride your back better. Even though as you warm up, you may increase blood flow to the lumbar region of your spine and decrease your pain level, chances are that the back will continue to produce pain. As a result, you will be riding with altered biomechanics. This is never a good idea because it will only increase your problem.
By Rick Rosa, D.C.,D.A.A.P.M.

What's going on inside my back?
If we go back over the items that we mentioned in the first article on back pain, we had spinal disease listed first. The obvious thing here is that you get the problem treated. If that’s some type of organic disease like metastasis, SLE, gout, etc. you need to get that disease treated first by your physician and then explore when and if you may return to the bike.

Now, if the cause is a herniated lumbar disc you should progress through conservative treatments first like chiropractic, physical therapy, nutrition, and medications (we combine these in my office). The earlier you get treatment the better the chances are for the inflammation and tissue to shrink so to speak and stop putting pressure or chemical irritation on the nerve root. I advise cyclists to get treated ASAP and to combine some of the conservative treatment options because this condition can be very difficult to treat for a cyclist.

Why you ask? Well, when you ride your bike you are in a flexed position and this tractions or pulls the nerve root over the herniation or disc material. Once you have been treated successfully for this condition, you can move into a rehabilitative phase where you can incorporate some of the methods I will present in the other treatment sections.

Not Good Reading…
If you don’t respond to conservative treatments, then what? In my clinic we then combine epidural blocks (injections of medication into the spine near the nerve) in a series of up to 3 total blocks for 3-4 weeks combined with various forms of traction and rehab. If all of this fun stuff still doesn’t provide you with the relief you’ve been searching for, surgery may be in your future. If this becomes the only option, you would want to go with a neurosurgeon that can perform a minimally invasive technique if they can and will be followed up with rehab.

Another spinal disease that may affect the more mature cyclist is Degenerative Joint Disease (aka Osteoarthritis). This is where a build up of bone can cause spinal stenosis (a decrease in the size of the hole where the spinal cord and spinal nerve roots travel through. It is a build up of bone due to various stressors being placed on the joints over time. In fact, most of us will develop at least a small amount of DJD over time but it is only when the spine or nerve roots become compromised where we get a serious problem. The symptoms are similar to a disc herniation but your doctor will obviously be the one that will determine your condition. The treatments are similar to the ones previously mentioned but the chances are smaller that you will respond to care.

Don't Fall
Of course we can’t forget to mention trauma. Oh the glorious pain of falling of your bike and if you haven’t yet taken a tumble, you will at some point. If you happen to fracture one of the vertebrae, you may have a medical emergency so don’t move your body. In a serious fall, let the EMT handle the situation. You don’t want a fractured spinal segment cutting into the cauda equina (bottom of spinal cord.) If your broken back does not require major spinal reconstruction and you don’t have a compression fracture of the vertebrae, then rest or a new procedure called vertebroplasy may be recommended. This is where they inject a cement like material into the bone to butteress the vertebrae from within.

In the best case scenario, you sprain your lumbar spine and this can be very painful. The amount of fluid that develops from the inflammation is a lot less then say your knee but the joints are much smaller and tighter. The result is pain. Typically, you strain the muscles of the spine which means you tear some of the fibers and strain the joint tissue which means over stretching of the ligaments. The worst part is the muscle spasms that are an inherent reflex mechanism that will be present the following morning when you wake up in pain and as stiff as titanium.

So what do you do? Well see your doctor (I know you are sick of me saying that) and you should begin a combination of acute care treatment, physical therapy, spinal manipulation, and proper nutrition and or medication. The idea is to decrease the amount of scar tissue formation, restoration of proper spinal biomechanics, decrease of inflammation and pain. Most cases responded very well to this combination of treatment and you will soon be in the final or rehabilitative phase.

In Part III I will discuss the final two areas, namely bike fit and the problems that occur from the act of cycling. You will be able to pick up there when you have recovered enough from the previous mentioned injuries.


1. White III,AA and Panjabi, MM:Clinical Biomechanics of the Spine. Lippincott Williams & Wilkins Baltimore ed. 2, 1990
2. Cilliet, R: Low Back Pain Syndrome. F.A. Davis Company Philadelphia ed 4, 1992
3. Cox, J: Low Back Pain. Williams & Wilkins Baltimore ed 5, 1990
4. Reilly: Practical Strategies in Outpatient medicine. Sounders ed 2 1984

Wednesday, May 20, 2009

Back Pain and Cycling

I think many of you might be surprised to hear that the number one complaint reported by cyclist has been back pain, with numbers ranging from 60-70% in various studies. The first question that should be answered is what the cause of back pain is for cyclist.

One interesting study was done by the British Cycling Federation on the squad medicals of its elite cyclists and found that 60% of the 500 elite riders had low back
pain. Bicycling is one of those unique sports where the human-machine interface is paramount. As we discussed previously when discussing cadence and PowerCranks, the repetitive and constrained motion of cycling is an invitation to injury if the interface is not optimal. While everyone can benefit from a top-notch bike fitting session, it’s not always the primary reason behind back pain, and the first question that should be answered is what the cause of back pain is for cyclist.

Four major sources of problems that may bring about back problems include:

1. The first cause can be some type of spinal disease that may or may not be related to the activity of cycling (i.e. Disc herniation, arthritis, metastatic disease.)

2. Acute trauma from a fall or crash while ridding like Tyler Hamilton had in the 2004 Tour de France.

3. Bike fit, from proper seat angle and height to stem length and drop position has been shown to cause back pain.

4. The biomechanics of cycling itself and your body’s ability to adjust.

First thing I would recommend that you have your back pain evaluated by a chiropractor, physical medicine specialist or orthopedic surgeon that has a background in sports injuries. One potential serious cause of back pain, namely spinal disease, can only be determined by a proper examination that may include x-rays, MRI, Bone scans and blood work. Due to the many cause of spinal disease some may limit or take you off the bike while others would actually benefit from riding. The key here is to have a proper diagnosis made so you can treat the problem properly.

Second, acute trauma from a fall or crash can result in a fracture of the spine which is very serious injury and should require immediate attention (except if your name is Robbie McEwen and you finish Le Tour 2004 and win the Maillot Vert anyway – wow!). If we don’t fracture the spine we can bruise the muscle and joint tissue and as well as cause a sprain/strain injury of the ligaments, tendons and muscle that support the spine. This can be very painful and would leave you with a significant decrease in power. This was evident a few years back at the Tour when Tyler Hamilton had to abandon due to back pain. Remember, this is the same guy who rode the Tour de France with a fracture collar bone the year before, so it’s not always something you can shrug off!

Bike fit is very important because small changes in biomechanics of the spine can lead to increase in load, stretch or compression on bone, muscle, ligaments and tendons. Seat position and angle, the length and angle of the stem, as well as the amount of drop of the handle bars all can contribute to low back pain and stiffness. Lastly vibration while riding can aggravate any symptoms you may have.

The biomechanics of cycling itself, even if perfectly fitted to the bicycle, can cause back pain. A study done In Australia in June of 2004 looked at muscle activity of cyclist that did and did not have back pain and they found that the more forward flexed the rider was during the test the more likely he was to develop pain in the muscles that are on each side of the spine ( lumbar erectors). In addition, a small spinal muscle that is a stabilizer called the lumbar multifidus muscle was not contracting when it was supposed to and the abdominal muscles showed decrease activity. Both muscles are spinal stabilizes. So what? You say. Well basically this sets up an imbalance and puts a large demand on the low back.

So what can you do to help yourself with any of these problems or better yet prevent them from occurring in the first place?

Check out part II of cycling and back pain.

Saturday, May 16, 2009

Jerry Rice Talks Chiropractic

Check out this article seen on

NFL Legend and Dancing With the Stars runner-up Jerry Rice has a formula for success that's grounded in hard work, a positive attitude - and chiropractic care. In fact, he attributes much of his long-term success to regular adjustments from his chiropractor.

Jerry Rice played in the National Football League for 20 years , which is an accomplishment in and of itself, considering the average NFL career spans only 3.5 years. Widely touted as the best receiver to ever play the game, his spectacular career included 16 seasons and three Super Bowl wins as a member of the San Francisco 49ers, followed by three seasons with the Oakland Raiders. (He was on the roster of the Seattle Seahawks when he retired in 2005). Rice was named to the Pro Bowl 13 times, winning the Pro Bowl MVP award in 1995, and received the Super Bowl MVP award in 1988. He held an amazing 38 NFL records at the time of his retirement.

With all the records and accomplishments, Jerry Rice is perhaps best known for his desire to succeed and his willingness to do whatever it takes to be the best. Consider what NFL Commissioner Paul Tagliabue had to say about Rice in an ESPN Classic documentary:
"One off my vivid images of Jerry Rice [is] him working out at the Pro Bowl. Here you are, after he wins the Super Bowl, he's played in front of 500 million people. Less than a week later, he's out there running wind sprints to play in [an] exhibition game." (emphasis added)
Not one to rest on his laurels after retirement, Rice signed on with the hit TV show "Dancing With the Stars" for the 2005-2006 season. Paired with dancer Anna Trebunskaya,
Rice finished second in the grueling competition, losing to Drew Lachey (who, along with brother Nick, sang in the pop group 98 Degrees) and dance partner Cheryl Burke. If you think the show was all smoke and mirrors, consider that participants, many of whom had little or no dance experience, formal or otherwise, had approximately six days to learn a new dance routine before each week's competition. According to reports, that sometimes meant practicing for up to five hours a day.

As much attention as Jerry Rice has received for his dazzling catches and amazing abilities, on and off the field, he has an important message to share about how to maximize health and wellness, regardless of whether you're an elite athlete, a weekend warrior or anywhere in between. Rice believes chiropractic has helped him tremendously over the years and wants others to experience the same results. Obviously, going to the chiropractor may not make you the world's best receiver (or dancer), but it can certainly help you live a happier, healthier life free from pain.

"Chiropractic care has been instrumental in my life, both on and off the field, and I am excited to share this with the American public," says Rice. "I have been blessed with a long and healthy career as a professional athlete, and as I move forward into the next stage of my life, chiropractic care will continue to be an important part of my game plan."
Rice credits chiropractic care in terms of his achievements on the gridiron, the dance floor and life in general. "Optimal health has been a key to the success of my athletic career, my dancing experience and my ability to enjoy my life to the fullest. Chiropractic care is an important part of my game plan for healthy living."

Jerry Rice is such a big supporter of chiropractic care that he recently became the official spokesperson for the Foundation for Chiropractic Progress (FCP), a nonprofit organization dedicated to promoting the value of chiropractic care to the public. The foundation is using Rice's image and message about the value of chiropractic care in various ways, including a full-page advertisement you may have seen recently in print. The ad already has appeared in the Dec. 15, 2008 issue of ESPN The Magazine, the January 2009 issue of Sports Illustrated, the Jan. 16/17 issue of USA Today, the February 2009 issue of Men's Fitness and the January/February 2009 issue of Women's Health.

Jerry now lives in the San Francisco Bay area with his wife and their three children. In addition to the FCP, he supports a variety of other worthy causes, including the March of Dimes, the United Negro College Fund and his own "127" Foundation. Undoubtedly, he is also preparing for his next life challenge. Whatever that is, two things are fairly certain: He will be successful at whatever he sets his mind to, and he will be better able to achieve his goal because of his lifelong commitment to chiropractic care.

Click here to see his personal testimonial on YouTube!

Tuesday, May 12, 2009

Team captain Christian Vande Velde crashed out of the Giro

Team captain Christian Vande Velde crashed out of the Giro in a spill with about 50km to go and suffered serious injuries that will complicate his preparations for the Tour de France.

Vande Velde broke two ribs and a severe contusion and sprain to his mid-back, said Garmin team officials.

“His front wheel got taken out,” said Garmin director Matt White. “He fell right in the middle of the road. I was with him within 10 seconds because we were the second car today. He was pretty upset. There’s no soft landing when you’re going 50kph.”

So what will happen to his tour preparations? Well they are altered at a minimum and he may have two very difficult injuries to build up to Tour form. First, fractured ribs are very difficult to treat but can be treated to speed up the healing time the largest problem is the pain when he breathes in and out and that causes an alteration in breathing habits that some feel can inhibit your cardiovascular development at this level. In addition, he has a history of back problems and this crash I am sure has flared things up. At those speeds we some times see compression fractures and disc herniation that can cause major issue with pain and discomfort. It is very difficult to generate any power when every time you press down on the peddles you have sharp back and leg pain and you can't breath because your ribs are fractured. In my clinic we have treated similar problems with sucess but a comprehensive recovery plan is a must or you have no chance of being race ready. Good luck to Christian Vande Velde I hope he has a speedy recovery.

Saturday, May 9, 2009

Running Shoes

Here's a great article featured on

How to Select Athletic Shoes

Too many people choose fashion over function when purchasing athletic shoes, not realizing that poor-fitting shoes can lead to pain throughout the body. Because footwear plays such an important role in the function of bones and joints—especially for runners and other athletes—choosing the right shoe can help prevent pain in your back, hips, knees, and feet.
Unfortunately, there is no such thing as the very best athletic shoe—every pair of feet is different, every shoe has different features, and overall comfort is a very personal decision. For this reason, it is recommended that you first determine your foot type: normal, flat, or high-arched.

The Normal Foot:
Normal feet have a normal-sized arch and will leave a wet footprint that has a flare, but shows the forefoot and heel connected by a broad band. A normal foot lands on the outside of the heel and rolls slightly inward to absorb shock.

Best shoes: Stability shoes with a slightly curved shape.

The Flat Foot:
This type of foot has a low arch and leaves a print that looks like the whole sole of the foot. It usually indicates an over-pronated foot—one that strikes on the outside of the heel and rolls excessively inward (pronates). Over time, this can cause overuse injuries.

Best shoes: Motion-control shoes or high-stability shoes with firm midsoles. These shoes should be fairly resistant to twisting or bending. Stay away from highly cushioned, highly curved shoes, which lack stability features.

The High-Arched Foot:
The high-arched foot leaves a print showing a very narrow band—or no band at all—between the forefoot and the heel. A curved, highly arched foot is generally supinated or under-pronated. Because the foot doesn’t pronate enough, usually it’s not an effective shock absorber.

Best shoes: Cushioned shoes with plenty of flexibility to encourage foot motion. Stay away from motion-control or stability shoes, which reduce foot mobility.

When determining your foot type, consult with your
doctor of chiropractic. He or she can help determine your specific foot type, assess your gait, and then suggest the best shoe match.

Shoe Purchasing Tips
Consider the following tips before you purchase your next pair of athletic shoes:

• Match the shoe to the activity. Select a shoe specific for the sport in which you will participate. Running shoes are primarily made to absorb shock as the heel strikes the ground. In contrast, tennis shoes provide more side-to-side stability. Walking shoes allow the foot to roll and push off naturally during walking, and they usually have a fairly rigid arch, a well-cushioned sole, and a stiff heel support for stability.

• If possible, shop at a specialty store. It’s best to shop at a store that specializes in athletic shoes. Employees at these stores are often trained to recommend a shoe that best matches your foot type (shown above) and stride pattern.

• Shop late in the day. If possible, shop for shoes at the end of the day or after a workout when your feet are generally at their largest. Wear the type of socks you usually wear during exercise, and if you use orthotic devices for postural support, make sure you wear them when trying on shoes.

• Have your feet measured every time. It’s important to have the length and width of both feet measured every time you shop for shoes, since foot size often changes with age and most people have 1 foot that is larger than the other. Also, many podiatrists suggest that you measure your foot while standing in a weight bearing position because the foot elongates and flattens when you stand, affecting the measurement and the fit of the shoe.

• Make sure the shoe fits correctly. Choose shoes for their fit, not by the size you’ve worn in the past. The shoe should fit with an index finger’s width between the end of the shoe and the longest toe. The toe box should have adequate room and not feel tight. The heel of your foot should fit snugly against the back of the shoe without sliding up or down as you walk or run. If possible, keep the shoe on for 10 minutes to make sure it remains comfortable.

How Long Do Shoes Last?
Once you have purchased a pair of athletic shoes, don’t run them into the ground. While estimates vary as to when the best time to replace old shoes is, most experts agree that between 300 and 500 miles is optimal. In fact, most shoes should be replaced even before they begin to show signs of moderate wear. Once shoes show wear, especially in the cushioning layer called the midsole, they also begin to lose their shock absorption. Failure to replace worn shoes is a common cause of injuries like shin splints, heel spurs, and plantar fasciitis.

Wednesday, May 6, 2009

Glycine propionyl-L-carnitine increase in Exercise Performance

I wanted to post a note about this article a while back but did not have time. I found this very interesting in that it may help develop Peak power and at a minimuim should warrent a larger scale study. Any Questions Just ask.

"Glycine propionyl-L-carnitine produces enhanced anaerobic work capacity with reduced lactate accumulation in resistance trained males," Jacobs PL, Goldstein ER, et al, J Int Soc Sports Nutr, 2009; 6(1): 9. (Address: Patrick L. Jacobs, Department of Exercise Science and Health Promotion, Florida Atlantic University, Davie, FL, 33314, USA. E-mail: ).

In a double-blind, placebo-controlled, crossover study involving 24 healthy male resistance trained subjects (average age: 25 years), supplementation with 4.5 grams glycine propionyl-L-carnitine (GPLC) 90 minutes prior to participating in an exercise testing protocol, was found to enhance peak power production and significantly reduce accumulation of blood lactate (16% less blood lactate production 14 minutes post-exercise), as compared to ingestion of a placebo. The authors state, "These findings indicate that short-term oral supplementation of GPLC can enhance peak power production in resistance trained males with significantly less LAC accumulation."

Testing: The assessment protocol consisted of five maximal effort 10-second cycle sprints performed with 1-minute active recovery periods between bouts. While Wingate type testing is typically performed using a single 30 second work period, repeated 10 second sprints have been used when testing exercise capacities similar to those required in relatively intense exercise. The sprints were performed using a Monarch 894E leg ergometer (Monarch, Varberb, Sweden) outfitted with pedal cages. The external resistance applied was equivalent to 7.5% of each subject's body mass. The testing protocol included a 10-minute warm-up period cycling on the test bike at a pace of 60 RPM, without external resistance. Following the warm-up period, subjects were directed to gradually increase the pace of their pedalling over several seconds until they reached a maximal pace of unloaded sprinting. At this point, with a verbal cadence, external resistance was applied thereby initiating a 10-second period of sprint testing and data collection. Verbal encouragement was provided by the investigators to continue sprinting at maximal pace throughout the 10-second bout. Subjects were directed to continue pedalling at a slower controlled pace during the 1-minute active recovery periods. With five seconds remaining in the recovery period, subjects were again directed to gradually increase their pedalling to a sprinting pace for the second sprint. This procedure was continued for a total of five 10-second sprint bouts.
Anaerobic power output of the sprints was determined using the SMI OptoSensor 2000 (Sports Medicine Industries, Inc., St. Cloud, Minn). Values of power output determined included peak power (PP) and mean power (MP) which in this case were the average values of power output during the first five seconds and total ten second period, respectively. The third power output measure was a value of power decrement (DEC) in which the difference in power output between the first and second five second periods are expressed as a percentage of the first.
Blood lactate levels were assessed using the Accutrend® Lactate analyzer (Sports Resource Group, Inc., Pleasantville, NY). The analyzer was calibrated using the standard control solutions prior to each testing session. Lactate values were determined at rest and post-exercise at minutes four and fourteen. Heart rate was measured using a Polar HR monitor system with values assessed at rest, during the final 5 seconds of each sprint as well as four and fourteen minutes following completion of the fifth sprint. Thigh girth was assessed using a Gulick tape with circumferential measurements taken 15 mm superior to the patella. Thigh girth was measured at rest and four minutes following completion of the final sprint interval.

Now I know the sample size was small but I think the methods are sound and the results are interesting and show a significant increase in anaerobic power.