EXERCISE INDUCED PAIN AND BOTANICAL SUPPORT

Is been a bit of a busy week at the office and not as much time to dive into my research update safari as I normally would. But this piece of research caught my eye. I had several patients that have been very committed to trying to make strength gains with new exercise routines, however feeling a little bit deflated by painful responses post exercise that make it difficult for them to stay on track.

Making muscle gains does involve some micro-tearing and stimulation of new muscle growth, and there's almost inevitably some degree of discomfort associated with it. It should be transient, and allow you to continue with you normal activities of daily living, and most importantly allow you to go back to another strength workout later in the week. If you're running into roadblocks achieving that, you may need to work with the seasoned trainer to try to 1st revisit the adequacy of your current workout routine: are you trying to do too much too fast, do not have proper pre-workout meal and hydration, do you have inadequate warm up and warm down recovery? Do you lack post exercise protein intake?

If everything tracks and you are still having difficulty recovering from your workout, you may need to introduce some supplemental botanical anti-inflammatory to speed up the post exercise muscle inflammation and its recovery. Curcumin (an extract of the spice turmeric but in much higher concentration than what found in the spice itself), has been the most studied substance to achieve that purpose. As this meta-analysis reveals, it's been a tried and true and very dependable agent to minimize post exercise muscular soreness. It has very little side effect 2. But there are some important details and how you use curcumin. You do need to have an adequate amount (about 2 g), and it's poorly absorbed unless combined with a fat-soluble base, and additionally enhanced by the addition of anti-inflammatory fatty acids (whether fish oil or black cumin seed oil). The high-end supplement industry has been quick to respond to the research by formulating new products aimed specifically at delayed onset muscle soreness recovery. I recommend taking them just before a workout if your anticipated strength training session is going to be no more than 30 minutes, or right after along with your protein bolus if your workout is going to be an hour or so.

NECK AND SHOULDER INJURIES FROM PLANKING

https://www.youtube.com/shorts/zGL8G0ZRHM0

Seeing 3 consecutive similar injuries in one week reminded me to blog about this and record a short instructional video. (Thanks to Louis for joining the effort.)

Planking is a great strength, stability and endurance exercise for both the shoulder girdle and the core. However it's also a demanding exercise with little margin for error without running the risk of injury. It does require excellent form, and since it's working multiple body areas at the same time, is more subject to fatigue. This particular video discusses the impact on the neck and shoulder from our plank gone wrong. When the shoulder girdle and torso muscles start to fatigue, the load is shifted to the anterior cervical spine especially. Your trunk and shoulder muscles are engineered and designed to be able to hold your body weight under certain circumstances during activities that humans engage in on a routine basis, but cervical muscles are not. They are primarily designed to hold the weight of your neck and head.

The collapse of the torso into the shoulder is associated with anterior cervical injuries, often affecting the anterior clavicle, and the brachial plexus. They can result in not only local neck and upper back pain but also headaches, anterior pain referring to the head and arm pain and weakness.

If you have not been practicing planking for a while, I strongly recommend you gradually work your way up to it: you can consider doing a countertop plank, then a partial plank from the knees up and onto elbows, before slowly working your way up to a full plank on your arms.

SHOULDER IMPINGEMENT SYNDROME

Shoulder pain and dysfunction can have a variety of root causes. Chiropractors will directly or indirectly address shoulder problems since a large percentage are related to poor function and alignment of the cervical spine and upper thoracic spine preventing normal alignment of the shoulder girdle. However in this particular blog I want to talk about the more intrinsic presentation of shoulder pain and dysfunction, called shoulder impingement syndrome.

Shoulder impingement syndrome is actually a bit of a broader umbrella itself. In a nutshell, it describes a problem whereby the space above the ball of the head of the humerus and the bony bridge of the a acromioclavicular joint is narrowed, causing a pinching of the structures located in between, mostly some of the rotator cuff tendons and the bursa.

Shoulder impingement syndrome can fall into 2 categories, which sometimes overlap:

– static impingement syndrome describes a more or less permanent narrowing that is not affected by the movement and position of the arm. This happens when there is for example a bony outgrowth on the inferior aspect of the acromioclavicular joint, or some calcification of the tendon. The impingement will be the same regardless of the position of the arm. Those tend to be more difficult to resolve conservatively, since there are fewer ways to impact the problem. Thankfully it's a minority of the shoulder impingement presentations.

– Dynamic impingement syndrome describes an impingement that is the variable based on the position and movement of the arm. The vast majority of impingement syndromes are in the anterior aspect of the shoulder, sometimes lateral, and infrequently posterior. The main reason for the anterior dominance have to do with modern humans tendency to have very dominant anterior shoulder muscles pulling them in a rounded forward shoulder position, as well as the fact that the shape of the acromioclavicular joint tend to slope downward in the front of the shoulder, thereby predisposing more easily to impingement in the front.

Presentation of dynamic impingement syndrome often is anterior shoulder pain, sometimes radiating down the arm, when the arm is repetitively moving above the head or to decide, especially if additional weight is held, more pain when the shoulders slumped forward, or if this pressure to the anterior arm such as when sleeping on that side. Shoulder impingement syndrome is often found in combination with other shoulder problems such as acromioclavicular bony spurs, anterior frozen shoulder.

Resolving a shoulder impingement syndrome requires to look at all the modifiable factors that can be corrected to improve the clearance of the humeral head in relationship to the acromion especially when the arm is lifted forward or to the side:

– alignment of the neck and upper back in relationship to the shoulder blades. Anterior neck postures, rounded mid back and shoulder blade well-positioned the humeral head forward, in an already narrow subacromial space.

– Muscular balance between the front and back of the shoulder, which often goes with the anterior neck and upper back posture. This will require some manual release of the anterior contracted musculature and some passive as well as active retraining of the posterior shoulder stabilizers.

– Chronic scar tissue in the bursa, rotator cuff tendons, and anterior joint capsules. Those can fixate the head of the humerus superior and anterior, effectively narrowing the subacromial space with little to no margin during arm flexion and abduction. Manual adjustments of the humeral head as well as very specific soft tissues scar releases important to resolve this.

– Scar tissue and myofascial adhesions in the muscle group known as "humeral depressors", which are deep axillary muscles, in charge of pulling the head of the humerus down during arm flexion and abduction in order to create a little more space for the rest of the rotator cuff tendons. I find that to be often the missing part of the treatment plan to resolve long-standing shoulder impingement syndrome when people have already been working with physical rehab.

– Revisiting some of the patient's chronic triggers from the activities: sleeping position on the side without adequate support of the cervical spine can set up a cycle of chronic recurrent shoulder pain. Technology has been a huge problem, especially as computer use requires less keyboarding and more computer mouse usage, with the arm chronically rotating anterior. Ergonomic modification of the placement and type of computer mouse can be really helpful.

Understanding the benefits and the limitations of functional GI microbiome testing

Testing functional GI markers, as many of our patients have found out, can be really enlightening when patients are dealing with unresolved chronic health and digestive issues. However this interesting recent article in the scientific journal Nature decided to take an in-depth look at what's “underneath the hood” of much of the microbiome portion of the testing. There is an enormous amount of scientific data about the importance of a balanced GI ecology, for its role in health and disease, but that has not always translated into very clear guidelines about on the ground consumer testing , about what's valid and what's still undetermined.

Direct Consumer Testing (the ability of a patient to directly order health tests from a company rather than through their physician) , has further added complication to an already shifting picture. Many of these companies are freelancing by experimenting with new methods that have not been fully validated, and developing interpretation tools that are still very much in their infancy.

This is not to say that there is no merit in doing stool functional testing. We do it pretty routinely and have found it in many instances to be the key to turning around somebody's health by getting the right data set to make new clinical decisions. But this is a word of caution about two different aspects of this sort of testing: the first one is that DCT options will put more power in the hands of patients, however it also may make them more vulnerable to being sold substandard testing products from a strictly clinical perspective. As the article pointed out, several labs fared quite poorly in the reproducibility of their own testing using the same sample. The second aspect is more nuanced. We have a lot of scientific data about the benefits of a balanced microbiome, however we're still rapidly evolving in our understanding of what's healthy and optimal, and we need to understand that when we are looking at raw data to not excessively extrapolate conclusions that are not supported by our current scientific understanding.

https://www.nature.com/articles/s42003-025-09301-3

OSTEOARTHRITIS AND MYOFASCIAL PAIN SYNDROME

An increasing percentage of our population is living above 65, and often for another 2 or 3 decades. This bit of good news if you're approaching that milestone (I am!), Is that you have 2 or 3 more decades to experience and hopefully enjoy life. The bit of bad news is that you will get to live out those 3 decades in a body facing increasing wear and tear.

Osteoarthritis refers to the process by which articular cartilage starts to deteriorate, leading to loss of joint space, and a constellation of associated structural findings and symptoms: instability, spurring, loss of normal motion, chronic pain and inflammation. It should be noted that osteoarthritis is not a linear finding correlating with simply aging. Some patients are more predisposed to osteoarthritis than others because of additional mechanical factors causing accelerated wear and tear on joints of the spine and extremities (which is why chiropractic research has shown some modulation of progressive osteoarthritis in many patient receiving care, reducing unnecessary mechanical stress). Other patients experience worse osteoarthritis because of metabolic factors that have to do with our poor nutrition, lack of blood flow from inadequate physical activity, and other complications from health issues such as medications, medical treatments etc.

One aspect of the constellation of osteoarthritis related findings and symptoms that is often missed or poorly understood is the secondary chronic myofascial pain syndrome and widespread trigger points. There are complex reasons for that that have to do with the local neurology of the deteriorating joint on muscular tone and control. Patients often are frustrated about what they believe to be a completely new problem, until we sit down and explain to them the correlation between myofascial pain syndrome and osteoarthritis, as being the manifestations of one common phenomenon. But there is something unnerving about patients suddenly feeling that every muscle tendon and ligament in their body is starting to hurt.

Myofascial pain syndrome and trigger pointsin the context of osteoarthritis should be treated both concurrently for the best results. Addressing the myofascial pain alone will have little to no lasting results since there's an upstream trigger. Joint adjustments, active range of motion exercise and strengthening, information control will hugely impact the severity of the myofascial pain. Conversely, only addressing the osteoarthritis will often fail to adequately resolve the myofascial pain since it often has become a self-perpetuating condition of its own.

Myofascial interventions in patients with moderate to severe osteoarthritis does need some modifications. Levels of pressure, frequency of treatment need to be adjusted down. Qualified soft tissue therapist know how to modify the treatment plan accordingly. Other supporting treatments that have found to be very effective are dry needling, traditional acupuncture needling with caution, as well as a variety of topical intervention such as infrared therapy and counter irritant topicals

https://pubmed.ncbi.nlm.nih.gov/36943163/

WHAT CAN GO WRONG WHEN YOU FALL ON YOUR ARM

https://www.youtube.com/shorts/kKP5KtWSxVw

We've seen so many of these injuries this week that I decided to record a short video with the help of my staff to review all the things that can go wrong when you fall on your arm. I thought it was an important educational material to have available since so many people fall and develop problems that they do not connect to the original incident. Especially since the area of symptoms may be far away from the point of impact on their hand and wrist.

Where the injury exactly will occur along the kinetic chain from the hand to the neck depends on a variety of factors, some of it having to do with the angle, and the speed of reaction and trying to break the fall. I've seen some patients develop along acute cervical disc herniations from the side to side during when they're caught off guard during the fall and the neck experiences a form of lateral whiplash. Probably more common are the areas along the shoulder girdle. I especially find that the sternal clavicular joint, at the end of the anterior kinetic chain, can be a source of continued misery and destabilization along the anterior neck and chest, often overlooked and even more often undertreated.

New low back and hip pain after a knee or hip replacement: the "long leg"

Several of our patients are opting in for planned joint replacements of hips and knees at this season, with the assumption that their work on their rehab and be ready to hit the ground for the season of outdoor gardening vacationing and general fun summer activities with some new and well-functioning hardware. This reminded me of a long-awaited blog as I've seen several cases last year.

I've been in practice 32 years and 1 of the most stunning improvement I've seen that affect my patients in my practice has clearly been the advancement in joint replacement. Minimally invasive, robotics, short recovery, they sometimes come with some challenges that need to be addressed so that the patient has the optimal recovery they're looking for by going under the knife. One such challenge is sudden changes in leg differential that can happen even when surgical intervention has been optimal.

The process of osteoarthritis and articular cartilage joint loss is a slow process that happens over years. The thickness of an intact joint versus that of a fully deteriorated joint can be over 1/2 an inch in difference. (Maybe closer to three quarters of an inch at the knee because of the presence of the meniscus). As a result, the leg affected could be easily an inch shorter from its original status, a process that the body will be able to mostly absorb over time due to its ability to slowly compensate at several levels including the sacroiliac, the lumbar spine, and the ankle.

A joint replacement will overnight reestablish the distance of a joint to its original state, and that can paradoxically be a real big problem. While the body can adjust to half an inch of difference in leg differential that gradually manifests over 2 decades, it doesn't have the ability to adapt to three quarters of an inch overnight. As a side note I should mention that our fine orthopedic surgeons have done an increasingly better job at trying to assess the leg differential and compensate for that during the surgery. But it's not always a perfect process and some surgeries come with inherently more difficulty in maintaining equal leg length, especially for people who have profound damage to the bone in which the prosthesis is going to be inserted (previous fracture of the limb, AVN, osteonecrosis, hip dysplasia, aggressive subchondral cysts to name a few).

The typical presentation looks like this: patient has successful surgery, discharge into rehab. Within a few days of starting to ambulate, they start developing intense pain on one side of their lower back and gluteal area, often the opposite side of the hip or knee replacement. Initially they write it off to limping prior to the surgery or after to the surgery, but the pain only deteriorates as they increase their walking time.

Sometimes the process goes on for a few years before I happen to see the patient. The history will reveal a pretty clear correlation between the surgery and are rather rapid onset of the new pain pattern post surgically and related to increase weight bearing time. During the patient's physical examination, when I observed them standing from the front to the back and walking, is a clear pattern of a very tilted pelvis, most often high on the prosthetic side. By the time the patient has been ambulating with an acutely acquired noncompensated long leg, did create some mechanical stress that will require some manual intervention with chiropractic adjustments, soft tissue mobilization and sometimes some balancing exercises. But as soon as is feasible in the body can tolerate it, I'll start inserting a heel or full-length foot lift gradually, to bring the pelvis and the lumbar spine to its original level. There is some real finesse and how you conduct the leg balancing, often having to start with a few millimeters at the time and increase by a couple millimeters every 2 weeks, and due to complications of mature hips and knees on the affected side, most often will require a full-length lift which sometimes will have to be external in the shoes. I should also note that we don't always have to compensate for the full deficit, but the body will often be able to adapt to approximately half of the leg differential and will just need to shim for the other half. However, the recovery by addressing the acquired long leg from a joint replacement can also be very dramatic and rapid, making everyone happy.

The moral of the story: if you are having some persistent new unilateral hip lower back or thigh pain after a lower extremity joint replacement, don't give up on yourself and be evaluated. It could be a relatively simple problem to resolve.

NEW YEAR RESOLUTION AND THE LIES ABOUT WEIGHT LOSS

https://www.nature.com/articles/s41591-025-03842-0?utm_source=klaviyo&utm_medium=email&utm_campaign=%28Friday%20Email%20-%20Chris%20Kresser%20General%20News%29%20Chris%27s%20Friday%20Favorites&utm_term=Nature%20Medicine&utm_content=Nature%20Medicine&_kx=ZpXBDTeEF9QJhwDqQXXrImrT_HpFsBz1ZlYMbsx_Vq0.my75y6

Getting healthy is obviously on a lot of people's minds this week. Hopefully not to fade away unnecessarily soon. And among these priorities is often trying to bring body weight and body composition in line with optimal metrics.

A couple of years ago I got into an argument with a colleague personal trainer. The topic was about pre-and post workout high-protein meals. He kept pushing highly processed protein breakfast bars on his clients, to maximize muscle gains from his prescribed exercise routines, and I had advised some of our common patients against that based on metabolic health research, steering them instead to try to meet those goals with a few high protein naturally occurring foods. His mantra was that regardless of the source the metabolic effect was going to be the same and that some of these designer foods were actually a better value. There was a fair amount of research already back then about the fallacy of that statement, and this most recent piece of research puts the last nail in the coffin of the flawed processed food theory.

What struck me about this piece of research is not necessarily the end result, which is in line with previous research, but the scale of the differential of weight loss/weight gain based on the food source. We're talking about DOUBLE the weight loss and weight gain by simply sticking with unprocessed foods. And you have to remember that everything else in micronutrient and calories were exactly the same between both groups.

Let me flesh this out in practical terms: for the same amount of calories, and the same amount of proteins versus carbohydrates, and unprocessed food has a vastly different metabolic effect on your weight. And you may wonder why? Whole foods interacts very differently with the receptors in our gut, especially natural GLP-1 receptors, leptin and ghrelin receptors, which are hormones associated with energy regulation and food seeking behaviors. Whole foods also have a completely different interaction with our normal micro biome, which is highly involved in weight and body fat regulation at the level of the brain through retrograde vagal pathways primarily. It's also noteworthy that designer foods, even those supposedly good quality high protein bars that are often the staple of many people in the gym rat world, are basically so chemically different from the food your brain is meant to encounter that it doesn't know what to do with it and gets very confused about its nutritional and energy value.

It's not that in the real world you'll never be grabbing for a quick food every so often, but it's to emphasize the fact that you never get to where you need to be metabolically if that's the rule rather than the exception. I continuously feel the question from patients, especially parents of teenagers, what's the best breakfast bar or protein bar they can give the kids as they fly out in the morning. I tell them the best bar is no bar at this point. Which often gets a lot of raised eyebrows. Hardly any of them are made with real ingredients, and none of them will have the metabolic effect of grabbing a piece of fruit with a piece of cheese, a boiled egg, some nut butter etc. With a little bit of planning, you can stock your home with whole foods that do not require any prep, but can be tossed into a go bag for those days where more food prep is not an option.