Chronic Leg Pain in Athletes- Part 1A

With winter sports season beginning, so does the season of more chronic leg pain in our athletes. I am going to start a mini series of Chronic Leg pain in athletes based on this research article, Chronic Leg Pain in Athletes.

Medial Tibial Stress Syndrome or MTSS is an exercise induced leg pain, more familiarly known as true shin splints. This is the most common chronic leg pain in athletes and actually occurs for almost 5% of all athletic injuries. MTSS is “described as exercise- induced pain along the middle to distal posteromedial aspect of the tibia, estimated incidence between 13-22% of injuries in runners and dancers and 35% in naval recruits.” With MTSS, there may also be an increase in discomfort with resisted ankle plantar flexion, such as jumping. 

Basically MTSS is a boney overload injury where the load on the bone causes “the tibia to bend during weight bearing activities causing a strain”. Then this strain will cause small damages inside of the bone which ultimately leads to changes and adaptation in efforts to strengthen the bone to decrease bending to occur.

Initially with MTSS most studies support rest as the most important recovery tool in early phase, others include cryotherapy, compression, elevation, stretching, physical therapy and pneumatic leg bracing. 

It is also recommended that “modifying training routines, stretching and strengthening the lower extremity, wearing appropriate footwear, using orthotics and manual therapy to correct biomechanical abnormalities, and gradually returning to activity.” 

Stay tuned for some stretches and exercise videos to help you at home.

Children, Junk Food and Some Alternatives (For "Big Kids" Too !)

https://www.npr.org/2021/08/11/1026816658/study-us-kids-diet-ultraprocessed-junk-food

The article published in JAMA this fall hit a raw nerve for me, as much as it was an affirmation of a project I have been brewing on for a while.

The stats on nutrition in the US are absolutely abominable. The average American, when honest, admits that their diet is not ideal, but the reality is much worse. A whopping 2/3 of the average food intake is “ultra processed foods”. In other words, junk with no nutritional values and a lot of toxic effect.

We could spend a lot of time bemoaning the issue, and going into the technicality of what is an ultra processed food (hint: a lot of things you probably consider not so unhealthy because our minds have been so desensitized to the concept of real food ). But I feel like my time could be better spent offering some solutions to the problem.

After 27 years of practice, I never cease to be surprised by how many times I get it totally wrong. This has played out often in the area of guiding patients to better nutrition. Offering solutions to the wrong problem is guaranteed to flop. In this instance, it means intensely bombarding patients with well intentioned nutritional information in great details, and badgering them about not following through.

After 25 years of this approach, it occurred to me that I was not offering the right solution, because I was not asking the right question. Even worse, I was not asking questions at all. The questions were are simple as: “What are the barriers preventing you from eating well when you state a strong desire to do so?”

It turns out that you do not always need to reinvent the wheel, or, as a great friend of mine describes, engage in the process of kicking open doors. There is a lot of good research on the barriers to healthy eating. Some of them are more complex to address (those pertaining to our deep rooted relationship to food taste, culture, upbringing and emotional support), while some others are more logistical and thus easier to resolve.

The LaZ Kitchen project was an organic reaction to the awareness of 4 major “barriers”:

• People have very little time to cook, they do not know how to cook, they do not like to cook, prep or clean up (the “lazy” rule of the LaZ Kitchen).

• People are concerned about the cost and affordability of cooking healthy meals (the “thrifty” rule of the LaZ Kitchen).

• People have ultimately little genuine knowledge of what is a healthy balanced meal. And they do not have a lot of time or interest in finding out (the “healthy” rule of the LaZ Kitchen).

• People DO NOT KNOW HOW TO MAKE THE PRACTICAL TRANSITION BETWEEN WHAT THEY KNOW OF GOOD EATING AND TRANSLATE THAT INTO FOOD SHOPPING AND PREPARING.

For the past three months, I have been quietly cooking up a storm in my own kitchen and coming up with a docket of recipes recorded in short videos with the patient help of my home videographer Pauline. There is nothing very polished about the end product, but it is the way real folk like you and I come up with real food to put on the table, that will not send us to the grave prematurely. I hope that you will find this a useful resource in bridging your gap to sound eating, and stay tuned for the content that we are continuing to upload every other week.

https://www.bwclinic.com/laz-kitchen

Why is Cervical Spine Disc Degeneration So Common ?

That was the literal question posed by a patient last week, who had realized that just about everyone else in her circle of friends and family had received the same diagnosis. It was a fair question and here is how I would respond:

• Design: The cervical spine is designed with maximum flexibility in mind for humans to be able to respond quickly to their environment, looking up, down, and to the sides rapidly and with ease. The cost of flexibility is susceptibility to trauma, and beyond a certain threshold, the cervical disc cannot recover and deteriorates.

• Repetitive Postural Trauma: The cervical spine has a normal forward curve that gives it a certain amount of stability to forces like jarring, brisk side to side movement, and compression from above. The modern lifestyle does a lot to disrupt the normal forward curve by forcing it into a straight or reversed position: everything is in front of us and below eye level. The recent addition of small devices like tablets and smartphones have us looking downward for prolonged periods of time more than at any other time in human history.

• Acute Trauma: Modern life has added high speed collisions as a potential trauma for which the cervical spine is completely unequipped. Prior to the 19th century, the highest acceleration injury to your cervical spine is likely happening when you trip and your head hits the ground, arguably a pretty hefty force. But vehicles travel at a speed of 70 MPH or higher, and the combination of a 70 MPH sudden deceleration times the mass effect of a vehicle is the type of force that our delicate cervical spine is not meant to handle. Over a lifetime, just about any person living in an industrialized country will have to contend with one good whiplash. And those types of injuries, often sustained during our early driving years, can set a pattern of early degeneration that will stick with you for a lifetime.

• Metabolic Changes Affecting the Longevity of the Spinal Disc: Probably a highly overlooked factor. The “chemical soup” of our body chemistry is the matrix bathing our spinal discs and facets joints, and that matrix needs to provide the repair nutrients and waste removal system to repair daily microtraumas as well as larger single traumas. The combination of the average highly inflammatory modern diets, low essential nutrients, environmental toxins, and low oxygen conditions of deconditioning are the perfect storm that compounds the other factors and limits the body’s ability to recover and repair.

Post COVID Brain Fog

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785388

I have hesitated to write this blog. We are all sick of COVID (although based on the latest MN hospital census, COVID is not sick of us yet…), and the controversy surrounding the management of this never ending pandemic is putting everyone on edge, often leading to unproductive discussions. However, this latest JAMA study was a compelling enough confirmation of what I have observed at the office for the past three months that I thought I would still stick my neck out and share a little info for those interested in hearing it.

The latest study was interesting, and sobering, as it improves upon previously gathered data in several ways-

• It uses a well established outcome measurement tool to assess and categorize cognitive impairment, rather than simply self reported symptoms.

• It looks at a broader array of COVID patients, not just patients with severe illness and hospitalization.

This intersects quite well with my office observations of the past three months. Post COVID symptoms of continued widespread soft tissue pain, cognitive loss (“brain fog”), and aggravated autoimmune symptoms are common and persistent for several months. For some reason, I have seen that more in women than in men. I have also noticed a unique temporal pattern of those secondary symptoms suddenly appearing about 2-3 weeks after the resolution of the initial upper respiratory symptoms, about 5-6 weeks after the initial infection, often catching patients off guard who thought they had fully made the corner.

The research into prolonged COVID seem to suggest that the infection can lead to the development of a dysregulated immune system stuck in pro-inflammatory mode, based on blood markers like cytokines and interleukins, which would explain why women and folks prone to auto-immune illnesses tend to experience that more frequently. There is some question about the possibility of a persistent low grade, relapsing viral infection hiding in the body, very much like chronic Lyme disease. For some reason, COVID really likes central nervous system tissue like the brain.

Based on some recent inter-professional discussions among colleagues in integrative health, I have started to use nutritional protocols very similar to those we use for auto-immune and inflammatory conditions, with some encouraging results. It would be very premature to talk about it in more detail, but we are certainly here to sit down with individual patients and try to come up with some solutions for what is otherwise a very challenging situation with few definite answers as of now.

The Cervical Spine, Meninges, and Spinal Cord Connection to Headaches

https://pubmed.ncbi.nlm.nih.gov/8610241/

I am reading through a backlog of research articles in the very few minutes available in my “free time” (of which there is little during Dr. Alvarez absence). I still remember the anatomical breakthrough research that was coming out as I was finishing chiropractic training, because it was a bit of a vindication for what our colleagues had been reporting from the longstanding clinical observations of many decades: there is a unique anatomical relationship between the upper cervical spine, especially some of the deepest and smallest posterior muscles at the base of the skull, the meninges (AKA outer connective tissue layer of the spinal cord and brain), and a host of poorly explained neurological symptoms: headaches, sensation of pressure, and tingling in the head etc. Chiropractors were reporting the ability to resolve some of those mysterious problems with specific adjustments and muscle work to the upper cervical area, but the camp of traditional neurologists were saying this was not possible since there was no anatomical basis for it. Until the newer dissection methods, tissue fixation techniques and higher resolution MRIs proved them wrong.

The so-called myodural bridge is a band of connective tissue that connects two very small suboccipital muscles to the dura mater at the lower brainstem. It is relaxed under normal conditions. It can be subject to increased tension after upper cervical injuries such as sports concussions, whiplash, and often from birth straining to the delicate upper cervical spine of a newborn. The resulting symptoms of increased meningeal tension are difficult to describe, but most commonly involve poorly localized headaches, a sensation of head pain when the neck is flexed, sharp pain at the base of the skull when looking up, a sensation of increased pressure in the head, eyes, sinuses and ears, a sensation of pressure and tingling in the face, a sensation of the head being too heavy for the neck etc. Specific chiropractic intervention and muscle work can be helpful and worth exploring.

The Fallacy of Artificial Sweeteners

https://www.npr.org/sections/health-shots/2021/10/07/1044010141/diet-soda-may-prompt-food-cravings-especially-in-women-and-people-with-obesity

In the busyness of life, I don’t always have the time or energy to crusade on all of my favorite pet peeves. There was a time in the past when I was much more proactive in spreading the word on the health risks of artificial sweeteners, and it is time to get back on my high horse about it.

The stakes are not negligible. The processed food and diet industry has done a great job at making us believe those fake sugars are benign or part of a weight management strategy. They are neither. The article that was just featured in JAMA talks about the paradoxical increase in obesity among overweight and type 2 diabetic patients who consume sugar alcohol like sucralose focused on the metabolic and weight impact. while other studies have also shown how remarkably bad those artificial sweeteners are for your gut flora and all the functional digestive disorders that follow.

The recent research focused on the brain’s response to artificial sugar. Basically, it totally confuses your brain’s self regulating mechanisms of appetite, satiety, and blood sugar management: the brain assumes that sugar is coming to the blood stream when exposed to a sweet taste in the mouth, but when the two factors are delinked, the body stops properly producing leptin to signal that your are full or fails to produce the right amount of blood sugar regulating hormones at the right time and in the right amount.

Be on the lookout for the widespread presence of those artificial sweeteners in food, especially food that is labeled “light” This can be anything from yoghourt to dessert, salad dressing etc. The labels will clearly list it ( sucralose, Splenda). Also beware that a lot of packages listing stevia actually have added erythritol and sucralose as the first ingredient. Two safer alternatives in small amounts would be stevia and pure monk fruit powder. But in the end, you just have to limit your intake of sugar and there is no real way around it. Some supplements can help you achieve a lessened sugar craving, such as inositol or gymnema lozenges, and those do not contain artificial sweeteners

Chiropractic for Patients Recovering from Major Leg Fracture

I have meant to write this blog for a very long time and the final nudge was our journey with the wonderful Ms. R, who was kind enough to lend her body for a few illustrative photos of her recovery after a hideous car accident.

One of the privileges of 25+ years in practice in the same location is that you can follow people over time and see some strong patterns emerge. One such pattern is the complexity of seeing patients deal with the long lasting domino effect of major lower extremity fractures and learning from those observations to be much more proactive about what to look for and how to intervene to optimize recovery, rather than the “wait and see“ approach, which often leads to predictable and unmitigated complications. Below is an outline of the steps I take when I work with a patient recovering from a severe lower extremity trauma.

I would define a severe lower extremity trauma as one that requires surgery, no weightbearing, and prolonged immobilization for at least 6 weeks. Obviously you can still have a lot of problems if your immobilization is less than 6 weeks or if you are allowed partial weightbearing, but the combo of the three is usually the perfect storm. I have seen just about every fracture you can imagine, and a few more in the last 27 years, but the most common one is a fracture dislocation combination of the ankle and foot, which requires requires surgical stabilization with hardware, prolonged time off the leg, and bracing or boot walking for several more weeks.

Week 1-6

• Manage the post trauma and post surgical pain. The pain can be brutal and the risk is to reach high levels of prescription medications to deal with it. I find that using a combination of plant based anti-inflammatory botanicals (tumeric, white willow, and boswellia for ex), mild muscle relaxers (magnesium, valerian root), topical agents (CBD, menthol), and sleep support supplements (kava, California poppy) can help the patients minimize the use of prescription agents for episodes of breakthrough pain rather than as a base. Physical and mechanical agents such as ice and TENS units, can also be useful.

• Address the beginning of compensatory injuries before they become a new problem. The use of crutches and walkers can easily cause shoulder injuries. If you cannot fully eliminate stress to the area, you need to be sure to get those minor injuries treated before they become major.

• Stimulate strong bone and connective tissue healing: make sure patients are engaging in activities that get their heart rate up and push oxygen to surgical sites (yoga breathing, upper body exercises). Consider a good supplement of collagen and bone matrix. Use infrared therapy pads to stimulate repair.

Week 6-12

Somewhere in that vicinity patients will start doing partial or full weightbearing on the affected limb. The compensatory stress will shift from the shoulder to the pelvis and lumbar spine. Patient will often need to be checked and adjusted more frequently during that time frame.

• Persistent swelling is a MAJOR problem in a high percentage of patients. It is often ignored although it can be very uncomfortable or frankly painful, and contrary to what patients are told, it does not always disappear over time. The reason is that trauma and surgery can create damage to the lymph system that needs to be properly treated and rehabilitated by a provider that is trained to do so (in our case, this would be Anne).

• Scar tissue and contractures can be addressed as patients exit the cast and are allowed to increase movement. This mostly requires careful manual assessment of the layers of soft tissues that have started to form adhesions to each other, and treat it with a variety of methods: manual, instrument assisted, and cupping.

12 weeks and beyond

• Lower extremity fractures can result in a new permanent leg length differential (longer or shorter than before). After 8-12 weeks of weightbearing, the leg will have fully “settled” and accommodated as much as it will. At that point, you can carefully evaluate for leg differential (visualization, physical, or X ray measurements) and fit the patient with the correct heel lift if applicable.

• Ankle fracture and subsequent surgical stabilization will often result in a permanent change to the shape of the foot arch (surprisingly it is often higher). A standard shoe and insole may no longer work, and some patients require custom orthotics to spend any amount of time on their feet comfortably.

• Prolonged immobilization and boot walking causes some persistent changes in the gait as well as a loss of position sense in the affected limb, which can result in poor balance. Gait retraining and balance exercises will be needed for most patients.

Cervicogenic Vertigo and Chiropractic: A Problem and a Solution From All Parts of the World

https://chiro.org/research/ABSTRACTS/Observation_of_Curative_Effect.shtml

Vertigo and dizziness are common symptoms we see in the office. They can be debilitating to a person’s quality of life and very frustrating to clinically workup since many contributing triggers need to be taken into account. The cervical spine is an often overlooked area of trigger but one that we see a lot. By the time patients consult us for that particular problem, they have often explored a lot of other sources and the spine is the last item on the list.

I came across this research paper from China, which describes a clinical study on vertigo, using single axis, very specific manipulation of the spine in a study with a control group. The results speak for themselves and remind me of a few enduring truths:

• Vertigo is a common problem all over the world.

• While “chiropractic“ is not a widely available health profession the world over, there are many health care practitioners from various professions that specialize in very specific analysis of spinal segmental dysfunction of the spine and correction thereof, because it is so powerful.

• Patients with vertigo really deserve a thorough specific spinal analysis to rule in or rule out a spinal functional lesion as part of their vertigo triggers.