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Nature Does Not Hurry: Yet Everything Gets Accomplished

Regardless of the injury, whether it is a bruise/contusion, sprain, strain, fracture, dislocation or surgical intervention, the body must go through the following three phases in order for the healing process to be complete. The phases are the inflammatory stage, repair stage, and remodeling stage. If anyone of these stages is not allowed to run its course, then the course of healing would be disrupted and chronic pain or discomfort would more than likely be the outcome.

After the initial injury, the body begins what we refer to as the “Inflammatory Stage”. There is a common myth that the health care profession has created. The myth, get rid of swelling. Swelling or Edema is an integral and important part of healing. We do want to allow edema, we also want to make sure that over the course of time, it is reducing properly. The “Inflammatory stage usually lasts up to the first 72 hours after injury. The body’s defenses are closing down the injury to bleeding as well as movement. The current theory is, there is a chemical in the edema (swelling) that actually inhibits muscle contraction. It is in this stage where the acronym RICE, Rest, Ice, Compress and Elevate is applied. This allows the body to set up the injury for the next stage of healing, the “Repair Stage”.

In the “Repair Stage”, the injury has allowed the bleeding to create a blood clot aka hematoma where the tear in muscle and tendon fibers in the cases of bruising, sprain/strains and dislocations, as well as bone fragment(s) in the case of fracture. We have all seen how a tear (laceration) or scrape (abrasion) heals when it occurs on the skin, the process is pretty much the same under the skin. There will be the “knitting” process occurring under the blood clot, and then reabsorption of the blood clot several weeks later. The acronym of RICE changes to MICE, Movement, Ice, Compression, and Elevation during the Repair stage. Whether we are utilizing MICE or RICE, the Ice, Compression and Elevation (using gravity) is to minimize additional swelling, or control swelling in the area of repair. This is a good time to discuss the Movement aspect of the Repair Stage.

The first aspect of Movement is just that. Range of Motion, we want to start moving the injured area through the several planes of motion. Returning motion as soon as possible is important for several reasons. First, it engages the muscle in activity, requiring fresh blood and pumping out the fluids associated with being sedentary or resting. Secondly, the movement starts to mold and align them fibers with the direction of stress loads associated with moving. Along with restoring motion we also start activating “isometric” contractions of the muscles for strengthening. An “isometric” contraction is one in which we tighten the muscles and there is no change it the muscle length. Think of keeping your leg straight and then tightening the muscles of the leg. This is an isometric contraction.

After a certain amount of range of motion and strength is restored, usually weeks 4 to 6 after the injury, we can start strengthening usuing “concentric” and “eccentric contractions. A “concentric” contraction is one in which the muscle fibers are shortening when we lift the weight. Think of the bicep curl, and bringing the hand to the shoulder. The bicep shortens. An “eccentric” contraction is one in which the muscle fibers lengthen, think of lowering the bicep curl with control, back to its original position (wrist moving away from the shoulder). The amount of stress to the muscles will be dependent on each individual, always keeping in mind “Tolerance”. If you feel “pain” stop, you’re stressing the area too much. I use the concepts of Periodization. Increase the volume (amount of weight), decrease the amount of repetitions, increase the frequency of work outs, decrease the duration of the workout.

The last phase of healing is the “Remodeling Stage”. This usually occurs around weeks 10 through 16. This stage of healing is when the fibers of the muscles are being utilized in a Sport Specific manner. Some people use Isokinetic/isovelocity machines (treadmills, stair-stepper’s, etc.), others go to the actual sport training. Again, always ease yourself back into re-entry and use the following as your guidelines, common sense, pain tolerance, and doctor’s advice if under a doctor’s care.




Attitude

Beyond natural ability and hours of training is Attitude. There are several aspects of attitude, from the mental thoughts of Victory, to the subtle more integral thoughts of focus and body awareness. It is this latter aspect of attitude that I am addressing in this article.

All aspects of attitude share one thing: The origin of attitude, which are our thoughts. I cannot begin to tell you how many times I walk into a training room or an off-skate practice and hear the sounds of a coffee shop as opposed to a training room. While many athletes are truly inspired to achieve the maximum out of their training, there are those that utilize this time as a social hour. Learn to treat the training room with respect, as you would a teacher. One where your own mind teaches you about energy, tension, stiffness, body mechanics, and even where movement begins and ends. Learn to save the conversation when going to and from the room. Do not be afraid to let someone know in a kind way that their conversation is distracting you from achieving your goals, and would be happy to talk with them after training.

An important aspect of attitude is knowledge. The winning athlete learns that the difference between being first vs. second is understanding energy. They learn how to save it, how to focus it, how to make it explode, when to make it explode and most important how to have it when their opponent doesn’t.

As a specialist in athletic injury we often study the movement of our patient to assess how the shoulder mechanics, or knee mechanics or gait patterns operate. There are many ways the athlete wastes energy. We have all seen it in others, or observed and felt it within ourselves. Every time an athlete carries their shoulders too high and the muscles have to support the elevation of the shoulder, energy is burning. Every time the feet flail out past the shoulder or elbow line, energy is burning. Every time the runner crosses their midline with their stride, they’ve added extra mileage to their run, more energy wasted. Now for the newsflash: with fatigue comes injury! With fatigue, we see the athlete’s mechanics become sloppy, and this is where injury occurs at its greatest. Injury is not the accident most people think it is.
One thing we all share in common is that when we get tired or fatigued, we revert to our “Foundations” of training. This is where the athlete will either get sloppy or demonstrate good form and technique to the last millisecond. One of the most important aspects of foundation work is body awareness. Probably most of you think that explosion of power is going to come from your quads (thigh muscles) and hamstrings. When in actuality explosion comes from where the wheel and track or ground contact.

The other night at a bout, I was watching veteran skater V. Lee Siren set-up for jammer position. This time, she decided to hang back behind the other jammer and up by the rail. As she set up for take-off, I could see her twist the toe of her back skate into the track, set her weight more to her back leg, then squat down. You could actually see her winding up her energy, so that when the whistle blew, there was going to be an unscrewing of the twist of her toe-off, which would travel from the ground through her foot, through her leg, through her center and explode. Whether or not V was aware of this when she set up or when she went through the take off, I’m not sure. What she did demonstrate was good foundational work, and technique. By the way, she blew past her opposing jammer and through the pack.

Many of us sit in awe of great skaters whether Mo Quadzilla, Demanda Riot, DeRanged, Krissy Krash, and the list goes on. We sit in awe because we realize or observe, that they take the time to focus on foundation. When an athlete “feels” the experience that their form is good, there is an instant gratification of YES! Mostly because even after years and years of hours and hours of training it still comes down to thought. Where am I holding tension, is my butt out too far, is my center too high, are my arms in tight or flailing? When they feel their movements were of good form and foundation, it is often a feeling greater than beating an opponent. It is a victory over “self”.

I hope the next time you find yourself in the training room; you remember Attitude, Respect, and good Foundation.




ACL RECONSTRUCTION
AUTOGRAFT vs. ALLOGRAFT

In last month’s issue we discussed the anatomy of the knee and how certain mechanism’s of injury effect certain structures of the knee. The Anterior Cruciate Ligament or ACL injuries are most commonly caused during an activity that involves a twisting or pivoting motion of the knee, causing the ACL to tear and creating a popping noise in the joint. In the United States there are approximately over a quarter of a million, yes, 250,000 acl reconstructions done per year. Right now, there are probably a lot of skaters, out there nodding there head and thinking, “yup, and I’m one of them.” For those of you who have already had the surgery, this article might be a little too late, but for those who have put off this decision, or are unsure as to which surgical procedure to have performed, I hope you find it informative.

The goal of surgery or any rehabilitative procedure is to restore normal or almost normal stability and the level of function you had before the injury, limit loss of function, and prevent injury or degeneration to other structures. Please keep in mind, that not all acl tears require surgery. This is a choice to be made by you and your Orthopedist.

There are two types of procedures regarding the actual ligament reconstruction, the “autograft” taken from the patient, and the “allograft” the use of cadaveric ligament. Despite the huge numbers of acl repairs per year, the debate continues to be placed on the patient’s plate as to which is better. Some of the disadvantages of using autograft (patient ligament) are pain from the secondary surgical site, possible infection of the harvest (secondary) site, scarring and tendinitis of the secondary site, as well as the commonly shared problems of the actual reconstruction, again scarring, tendinitis, patellar fracture, infection, etc... Some advantages of the autograft are lower surgical costs, lack of cell death, improved graft incorporation (acceptance and usage of graft) and lack of donor to host disease transmission. By contrast the allograft avoids possible infection, scarring, tendinitis at the harvest site, shortens the time in surgery significantly, and provides less pain to the patient due to no secondary harvest site.
Since both procedures have their inherent pros and cons let’s bring in the recovery aspect of the procedures. On average the recovery time for most people is approximately 7 to 9 months before return to full activity. This is better summed up that after about 16 to 20 weeks (4 to 5 months) the patient is doing full activity, but the actual “healing” process will continue much longer. Obviously, certain factors affect this outcome such as the physical condition of the patient before surgery, the age, smoker vs. non-smoker, diet/nutrition and determination and desire of the patient pre and post operatively. Full muscle strength and endurance may take up to 2 full years to reach post operative status, and again this is based on multiple factors as stated above.

Patients, who go with autograft procedures, usually have a rougher initial recovery due to the surgery requiring 2 sites; the acl repair, and the harvest site. Due to the possibility of surgically induced infection as well as the tendency to see greater patellofemoral (the way the femur and knee cap articulate) complications in autograft procedures, patients with allografts, may be released sooner to perform cutting/agility moves.
By contrast, the allograft tendons have shown slower graft incorporation then the autograft which may make recovery time equal for both allograft and autograft procedures. One of the possibilities involved with allograft incorporation is the body’s failure to accept the foreign tissue, if this happens then the graft can give way easier when the patient returns to activity.

Many studies have been done to determine which graft is the best option for ACL replacement. Although these studies provide good insight into the different options, it is still unclear which is the best, and in the end, leaving the decision for graft type up to the surgeon as well as the patient.
Ultimately the graft choice is up to the patient. Once the patient has decided on the graft they want, they need to present their choice to the surgeon. As stated earlier in this article, at this point in time the autograft is still considered the Gold Standard of treatment.
Next month I will be talking about the rehabilitation of an ACL tear covering exercises for both the surgical and non-surgical procedures.
Wishing you a Very Safe and Happy Holiday Season.
-Dr. Rick




UNDERSTANDING YOUR LOWER AB WORK-OUT

This month I would like to address the misconception of “lower ab” work outs. To start with, there is no such muscle as the “lower ab”. The lower ab is just part of the rectus abdominus muscle which is a superficial (close to the skin) muscle. It attaches from the rib cage and inserts into the pubic ramus (the sitting) bones of the pelvis.

To try and recruit the “lower ab’s” would be like trying to reach for a glass and just recruite the short head of the bicep and not the long head, or to try and recruit just the medial head of the tricep and not the lateral or long head of the triceps muscle. It is physiologically impossible.
Training the ab’s usually consists of a combination of the following exercises: standard sit-ups, crunches, knee-ups, Roman-chair sit-ups, lying leg raises, and various twisting moves applied to the above exercises.

Athlete’s and trainee’s usually perform these exercises because they were “instructed” to do so, and not through an understanding of the anatomy and how the muscles work. Rather, they have been instructed to do so by their trainer, or because they saw them done in a commercial dvd, magazine, or gym.

The abdominal muscles are the rectus abdominus, and the “oblique” muscles, which as previously stated lay superficial or close to the outer body. The rectus abdominus is centrally located and consists of two rows of muscle with “horizontal” fibrous bands running across the upper portion of the muscle. The obliques consist of the internal and external obliques and are located on the sides of your waist. These muscles work together in a movement we call trunk flexion, or bringing the shoulders to the pelvis.

The muscles that most people are working out when performing “lower-ab” work-outs are actually the hip-flexor muscles, in specific the psoas major, the iliacus and the proximal or close end of the rectus femoris (the longest strand of muscle in the front thigh). The psoas major muscle attaches from the lower back or lumbar spine and disc’s and lays deep in the abdominal cavity attaching to the hip. The iliacus muscle lays deep in the floor of the pelvis and attaches to the hip.

The action of the hip flexor’s is to bring your knee’s to your chest—the main difference being spinal flexion (shoulder’s to chest) vs. hip flexion (knee’s to chest). So to get a clear understanding, the abdominal muscles attach from the rib cage to the pelvis and not the hip, whereas the hip flexors attach from the spine, discs, and pelvis to the hip or upper thigh.

The main problem with many of the ab exercises is the hip flexors act on the spine very much like pulling the string of a bow in a bow and arrow. They actually pull the spine more forward, which creates more of a “sway-back” or increased lumbar curve. This puts more weight on the hinges (facet’s) of the spine and can lead to low back pain. Even more importantly, it is counter-productive to training your ab muscles, which would pull the pelvis backward and upward. Thus, decreasing the lumbar curve.
The only action of the abdominal muscles during a hip-flexion movement is an isometric contraction, which is the weakest form of muscle training. There is absolutely no movement in either lengthening the muscle or shortening the muscle once we recruit hip flexion. So in essence, when doing hip flexion movement’s, the ab’s contract and are held isometrically to stabilize the pelvis while bringing your knee’s to your chest.
Since we are instructed to perform these exercises in “high” repetitions, we keep the abdominal muscles in a sustained or prolonged isometric contraction. Now here is a fun experiment that is easy to do. Make a real tight fist, and hold it for 15 to 30 seconds. See all the white around the knuckles, this means not much blood is getting to this area, what we call hypoxia. With the decreased blood flow in a sustained isometric contraction, we see less oxygen which will fatigue the muscle, we also see less picking up of waste products, leading to lactic acid build up. The classic “ab-burn” is nothing more than just excess muscle fatigue and toxicity due to poor oxygen supply.
While all this is happening to the “ab’s”, the hip-flexor’s are firing deep in the abdominal and pelvic cavities. Eventually, these lower-ab exercises will lead to increased low back curve, which will add to increased low back pain in your work-outs, as well as your daily activities.
If you are truly working out your “ab’s” by doing shoulder to chest movements, your ab’s will be there. If you can’t see your ab’s, it is not because of your workout, rather because of excess body weight. As we pointed out earlier, the ab’s are superficial or close to the outer body. If there is excess fat, or spare tire It needs to be burned off in order to see that 6 pack. Do not fall for gimmicks like “electric-ab’s” rest while you workout, or fad “fat-burners”. Good nutrition and eating habits are as important as the workout itself.
This is why it is important to have a well rounded routine of Attitude, Speed, and Strength Conditioning, Flexibility and Agility. Always allow for active recovery from your workouts so as not to create an overuse injury.




Concussion Syndrome

In this issue I would like to address what is referred to as Concussion Syndrome or Concussion. A traumatic blow to the head usually causes a concussion, but not always. Receiving any kind of “violent” whipping motion from the diaphragm up can cause it.
An important factor to keep in mind when evaluating for a concussion is that concussions can be immediate, come on within minutes or be delayed for hours to even a couple of days.

Concussions are common in contact sports such as Roller Derby, Football, Rugby and so on. The brain tissue is about the consistency of gelatin, and floats in a fluid known as cerebrospinal fluid that acts like a cushion for everyday type of jolts to the head. However a violent blow or shaking of the upper torso can cause the brain to slide back and forth forcefully against the inner wall of the skull. The concussion occurs because as with most injuries there is a certain amount of swelling that occurs. In the head the swelling pushes against the skull and onto the brain causing the concussive symptoms that alter your brain functions. These effects are usually temporary and can include problems such as headache, difficulty in concentration, memory loss, poor judgment, balance and coordination problems or any combination of all of the above. It is important to note that in some cases this may lead to bleeding in or around the brain causing prolonged drowsiness and confusion. This may develop immediately or over a period of time, which is why it is important to monitor a person with suspected concussion syndrome. After a concussion, the levels of brain chemicals are altered. It usually takes about a week for those levels to stabilize again, although it can vary depending on the extent of the trauma, and/or repeated traumas.

As stated above the signs and symptoms of a concussion can be subtle and may not be immediately apparent. Signs and symptoms you want to look for are: headache, confusion, amnesia, dizziness, ringing in the ears, nausea and/or vomiting, slurred speech, fatigue. These symptoms can last for days, weeks or even longer.

There are certain risk factors that make someone more susceptible to concussions and they are: People who are involved in high contact sports such as Roller Derby, Football, Soccer, Hockey, Cheerleading, being involved in a motor vehicle accident, domestic violence or abuse, falling especially in the elderly or young children, having had a previous concussion.

Some potential complications of a concussion include: Cumulative or additive effects of multiple brain injuries. Recently we have seen studies on football players receiving brain autopsies showing the amount of scar tissue that occurs from multiple hits to the head, even while wearing protective helmets. “Second Impact Syndrome” this occurs when receiving a second concussion to the head before the symptoms of the first concussion have resolved. It may result in rapid and typically fatal brain swelling. Epilepsy, people who have suffered a concussion double their risk of developing epilepsy within five years after the injury.

Recently I have started testing for another type of concussion, one that involves the inner ear, known as a vestibulocochlear concussion. This is often missed and is easily detected by checking vertical and horizontal gaze. I’ll put two fingers up in front of the athlete and say, “I want you to take your eyes and look back and forth between my two fingers without moving your head, and I want you to look up and down between my two fingers using just your eyes.” For someone who has a headache or is nauseous this can be difficult. If you see any lag of the pupil on movement or a jumping of the pupil, do not let the athlete return to play and have them follow up for further medical care.
Concussions are typically mild but can be serious or life-threatening/fatal. Make sure that you are familiar with the signs and symptoms and do not let a teammate return to play if any symptoms are present.


Core Training

It seems like every time I turn around there is a new catch phrase describing some form of health care or exercise. The good news is there is nothing new under the sun, just the same old thing with a new name!

What is “Core” training? We hear it all the time. “We must develop the core…” Simply put the “core” is the trunk of our body. It is everything from the base of the skull to the bottom of the knees. Movement of the body is highly dependent on the core, and lack of developing the core can create a person to be at greater risk for injury

The major muscles that are included in the core are the muscles of our pelvis, the abdominal muscles including the oblique’s and transverse, the deep muscles of the spine and to a lesser extent the latissimus dorsi, gluteal muscles and the trapezuis muscles. However, more important than the “major” muscles are the “intrinsic” muscles of the spine. The Deep muscles that go from spinous process to spinous process, from spinous process to transverse process and from transverse process to transverse process.

In general the core determines and contributes to a great extent the posture of a person, and is assumed to be the source of most of the full body functional movement, especially in sports. The core muscles align the spine, ribs and pelvis of a person to resist a specific force. Whether running, jumping, swimming, stretching, or resistance training, the core muscles are believed to be the origin of movement.

Due to the nature of movement, whether it is quick responsive movements associated with sports like racquetball, tennis, basketball, skiing, surfing, dancing, or the more methodical sports such as cross country skiing, hiking, biking, yoga, tai chi we must move in a manner to resist a force that changes its plane of motion. This causes the bones to have to absorb the resistance in a fluid manner, and this makes the tendons, ligaments, muscles and the nerve firing take on different responsibilities. These responsibilities include the speed in which a muscle may have to fire, the reactions to postural changes, and of course the power component.

Over the course of being involved with athletic injury and rehabilitation, I have seen many wonderful and many crazy concepts to make a body strong. The one’s that make the most sense to me are the training methods that start with a good foundation and then build from there. For example, before starting to do “core” workouts with or on a ball, make sure you have mastered the “feeling” of a strong core with what we refer to as a dry land practice.

Practicing the static dry land stance is a great place to start, as we develop core strength for more advanced techniques and sports. Another benefit from practicing core exercises is the strengthening of the pelvic floor, which helps prevent and control incontinence problems as we lose muscle tone here from aging.

For consultations on proper core training, as well as general strength conditioning and training tips, please ask one of our friendly staff members to schedule a consultation with Nikko our head trainer.

If you have any questions you can always contact me, Dr. Rick, at (323) 334-7921.


ICE IS FOR DRINKS NOT INJURIES

Over the last 28 years that I have been a doctor, there has been great controversy over what to do when an injury first happens. Should we ice, should we apply heat? Well, the very first thing after an injury first happens is to make sure they have a pulse further down from the injury to make sure blood is getting past the injured area. After that has been checked, we get into the debate of ice vs. heat.

For a period of time I followed the current trend of “icing” an injury to reduce swelling, and help numb the pain. The theory of icing made sense to me, at least until something else I read made more sense. The theory behind applying ice to an injured area is to reduce the amount of inflammation (swelling, redness and heat) by closing down the blood and lymph flow to the area, and pushing the fluid that is in the area away from there through a process known as vasoconstriction (constriction of the arteries and veins), whereas heat will open up the arteries and veins through a process of vasodialation. It had made sense to me to clear the fluids out of the injury site very much like taking cars off a freeway before letting more cars on.

One of the questions I like to ask Chiropractic students is, “Why do we ice”? Their typical response is a correct one; “to reduce inflammation, Dr. Fox”. My reply is, “what is the first stage of healing?” One student will almost always shout out, “The Inflammatory stage, Dr. Fox!” I say, ”correct the inflammatory stage, so we are trying to control the very 1st stage of healing? We know more than nature?” I then repeat my original question of, “Why do we ice?” Now no hands go up! I respond, because we believed someone who told us to, just like we used to believe the world was flat!”
The problem with icing is that we are taking something very hot, an injured area, and dropping the temperature rapidly, and doing so for at least a minimum of 20 minutes. I’ve heard of people leaving ice on an injured area for hours! If we take a simple example of water, as we freeze it, the water becomes thicker and thicker until it eventually forms ice. Same with the body, except we are not forming ice, we are creating what is known in Traditional Chinese Medicine as “The Beaver’s Dam”. We are taking blood, lymph, and other materials and creating a blocked area for blood to flow through.

In Chinese medicine Qi (life-force) nourishes blood, and blood moves Qi. If the blood is not flowing through an area then we have stagnation occurring at the site and below the site. It is said, “stagnation, is the cause of pain”. From what I have personally seen and experienced, I would agree with this. Once the Beaver’s Dam (or adhesions/scar tissue in western medicine) is formed it can take substantial time, work and money to break the Beaver’s Dam. Not to mention, it can be a very painful process in some instances.

So, when it comes to a new injury we want to “cool” the area down. This can be done by placing two layers of towels between the skin and ice pack and leaving the ice on for no more than 10 minutes out of every hour. If it is a wrist/hand, elbow or ankle, I like to recommend Cold Water soaks for about 15 – 20 minutes out of every 2 hours. The cooling process draws the heat out of the area, helps numb the pain, and allows blood to flow to the areas further down from the injury. In fact western medicine is beginning to take this approach in post surgical procedures using what is known as a “Chill-down unit” merely a cooler filled with ice, water and a fish pump and hose that flows through a pad wrapped around the surgical site.

So remember Ice is great in your drinks, and should be used only to cool down an injury.
-Dr. Rick




Nature Does Not Hurry: Yet Everything Gets Accomplished

Regardless of the injury, whether it is a bruise/contusion, sprain, strain, fracture, dislocation or surgical intervention, the body must go through the following three phases in order for the healing process to be complete. The phases are the inflammatory stage, repair stage, and remodeling stage. If anyone of these stages is not allowed to run its course, then the course of healing would be disrupted and chronic pain or discomfort would more than likely be the outcome.

After the initial injury, the body begins what we refer to as the “Inflammatory Stage”. There is a common myth that the health care profession has created. The myth, get rid of swelling. Swelling or Edema is an integral and important part of healing. We do want to allow edema, we also want to make sure that over the course of time, it is reducing properly. The “Inflammatory stage usually lasts up to the first 72 hours after injury. The body’s defenses are closing down the injury to bleeding as well as movement. The current theory is, there is a chemical in the edema (swelling) that actually inhibits muscle contraction. It is in this stage where the acronym RICE, Rest, Ice, Compress and Elevate is applied. This allows the body to set up the injury for the next stage of healing, the “Repair Stage”.

In the “Repair Stage”, the injury has allowed the bleeding to create a blood clot aka hematoma where the tear in muscle and tendon fibers in the cases of bruising, sprain/strains and dislocations, as well as bone fragment(s) in the case of fracture. We have all seen how a tear (laceration) or scrape (abrasion) heals when it occurs on the skin, the process is pretty much the same under the skin. There will be the “knitting” process occurring under the blood clot, and then reabsorption of the blood clot several weeks later. The acronym of RICE changes to MICE, Movement, Ice, Compression, and Elevation during the Repair stage. Whether we are utilizing MICE or RICE, the Ice, Compression and Elevation (using gravity) is to minimize additional swelling, or control swelling in the area of repair. This is a good time to discuss the Movement aspect of the Repair Stage.

The first aspect of Movement is just that. Range of Motion, we want to start moving the injured area through the several planes of motion. Returning motion as soon as possible is important for several reasons. First, it engages the muscle in activity, requiring fresh blood and pumping out the fluids associated with being sedentary or resting. Secondly, the movement starts to mold and align them fibers with the direction of stress loads associated with moving. Along with restoring motion we also start activating “isometric” contractions of the muscles for strengthening. An “isometric” contraction is one in which we tighten the muscles and there is no change it the muscle length. Think of keeping your leg straight and then tightening the muscles of the leg. This is an isometric contraction.

After a certain amount of range of motion and strength is restored, usually weeks 4 to 6 after the injury, we can start strengthening usuing “concentric” and “eccentric contractions. A “concentric” contraction is one in which the muscle fibers are shortening when we lift the weight. Think of the bicep curl, and bringing the hand to the shoulder. The bicep shortens. An “eccentric” contraction is one in which the muscle fibers lengthen, think of lowering the bicep curl with control, back to its original position (wrist moving away from the shoulder). The amount of stress to the muscles will be dependent on each individual, always keeping in mind “Tolerance”. If you feel “pain” stop, you’re stressing the area too much. I use the concepts of Periodization. Increase the volume (amount of weight), decrease the amount of repetitions, increase the frequency of work outs, decrease the duration of the workout.

The last phase of healing is the “Remodeling Stage”. This usually occurs around weeks 10 through 16. This stage of healing is when the fibers of the muscles are being utilized in a Sport Specific manner. Some people use Isokinetic/isovelocity machines (treadmills, stair-stepper’s, etc.), others go to the actual sport training. Again, always ease yourself back into re-entry and use the following as your guidelines, common sense, pain tolerance, and doctor’s advice if under a doctor’s care.




STRETCHING!

One of the easiest ways to avoid an injury, and stay out of any other doctor’s office or mine is to make sure you stretch before you do your workout. Stretching helps in at least two areas that we are aware of. First, it brings blood to the muscles so our muscles have increased oxygen supply for the demand we are about to put on them, as well as blood sugar, which is necessary for energy we are about to burn. Secondly, it brings greater joint motion, by giving greater range of motion to the joints. This helps prevent muscle, tendon (attaches muscle to bone) and ligament (attaches bone to bone) tearing. It also helps the joints become stronger and lower the risk for sprain/strains and broken bones or dislocation injuries.

There are a lot of ways to stretch from one-person styles to two person styles, yoga, tai chi, stretch classes, and believe it or not, there is a right or proper way to stretch! The nice thing about stretching is it is something that is good for you and can be done anywhere, at your home, at the park, a hotel room or even at the office! One very important thing to understand is that improper stretching can do more harm than good.
Do NOT consider stretching as a “warm-up”! When you stretch “cold” muscles, there is a good chance you can tear them. Start off with a light walk, jog, stationary bike, treadmill, or elliptical machine for at least 10 minutes to get the blood flowing, and the muscles warmed up. The key word in that last sentence is “LIGHT”!!! Another thing is understood when you want to stretch a muscle vs. not stretching. Believe it or not, research shows that Sprinters who stretch before their event actually decrease their time. In this sport or case the athlete needs the explosive power of a greater tension in their body.

Since movement requires many muscles to perform an action, and not “isolated” like many bodybuilders like to think, focus on stretching “major” muscle groups. Focus on the thighs, hips, calves, lower back, neck, chest shoulders and especially the quads. The reason I say especially the quads is all sports that require running, walking, jumping, bouncing will use the hip flexors. The hip flexors attach to the front of the pelvis, upper thigh and spine. These muscles are already tight due to being in a shortened position from all the time we spend sitting over so many years.
Remember we are trying to stretch a muscle to avoid or prevent tears, therefore Do Not Bounce when stretching! Tearing a muscle creates a knitting process you might have read about in my previous articles, and this “knitting” process leaves scar tissue. Scar tissue does not have the same elastic qualities of muscle.

Avoid stretching for pain, but focus on feeling “tension” of the muscle. If you are feeling “pain” then you are pushing or stretching too far, just back off on the tension until you don’t feel the pain anymore.

Try and focus your stretching on being sport specific, if you are in roller derby for example, make sure to really stretch the calves, hamstrings, quads, inner thighs, hips, back, neck and shoulder muscle groups. Keep up with your stretching make it a part of your training and pre-bout program. As I said in the beginning of this article, proper stretching can keep you out of the doctor’s office and enjoying your wonderful summer of activity and BBQ’s!

I am mentioning this part last as it is probably the most important part of stretching. Make sure when you go into a stretch that you focus on slow movement and movement that opens the joints of the pelvis, back, shoulder’s, neck, arms and legs. Do not just drop into a stretch. Secondly, make sure you exit a stretch in the same way you enter it, slowly with mindfulness of movement as at this point you are relaxing the muscles and closing down the joints!

And remember to use your breath as you stretch, as breathing is very important!!!
-Dr. Rick




UNDERSTANDING YOUR INJURY

Regardless of the injury, whether it is a bruise/contusion, sprain, strain, fracture, dislocation or surgical intervention, the body must go through the following three phases in order for the healing process to be complete. The phases are the inflammatory stage, repair stage, and remodeling stage. If anyone of these stages is not allowed to run its course, then healing would be disrupted and chronic pain or discomfort would more than likely be the outcome.

After the initial injury, the body begins what we refer to as the “Inflammatory Stage”. There is a common myth that the health care profession has created. The myth, get rid of swelling! Swelling or Edema is an integral and important part of healing. We want to allow for edema! We also want to make sure that it does not impede blood flow and over the course of time, it is reducing properly. The “Inflammatory stage usually lasts up to the first 72 hours after injury. The body’s defenses are closing down the injury to bleeding as well as movement. The current theory is, there is a chemical in the edema that actually inhibits muscle contraction. It is in this stage where the acronym RICE, Rest, Ice, Compress and Elevate is applied. This allows the body to set up the injury for the next stage of healing, the “Repair Stage”.

In the “Repair Stage”, the injury has allowed the bleeding to create a blood clot (aka hematoma) where the tear has occurred in the muscle and tendon fibers, in the cases of bruising, sprain/strains and dislocations, as well as bone fragment(s) in the case of fracture. We have all seen how a tear (laceration) or scrape (abrasion) heals when it occurs on the skin; the process is pretty much the same under the skin. There is the “knitting” process occurring under the blood clot, and then re-absorption of the blood clot several weeks later. The acronym of RICE changes to MICE, Movement, Ice, Compression, and Elevation during the Repair stage. Whether we are utilizing MICE or RICE, the Ice, Compression and Elevation (using gravity) is to minimize additional swelling, or control swelling in the area of repair. This is a good time to discuss the Movement aspect of the Repair Stage.

The first aspect of Movement is just that: Range of Motion. We want to start moving the injured area through the several planes of motion. Returning motion as soon as possible is important for several reasons. First, it engages the muscles in activity, requiring fresh blood and pumping out the fluids associated with being sedentary or resting. Secondly, the movement starts to mold and align the fibers with the direction of stress loads associated with moving. Along with restoring motion we also start activating “isometric” contractions of the muscles for strengthening. An “isometric” contraction is one in which we contract the muscles and there is no change in the muscle length. Think of keeping your leg straight and then tightening the muscles of the leg.

After a certain amount of range of motion and strength is restored, usually weeks 4 to 6 after the injury, we can start strengthening using “concentric” and “eccentric contractions. A “concentric” contraction is one in which the muscle fibers are shortening when we lift the weight. Think of the bicep curl, and bringing the hand to the shoulder. The bicep shortens. An “eccentric” contraction is one in which the muscle fibers lengthen think of lowering the bicep curl with control, wrist moving away from the shoulder. The amount of stress to the muscles will be dependent on each individual, always keeping in mind “Tolerance”. If you feel “pain” stop, you’re stressing the area too much. I use the concepts of Periodization. If you increase the volume (amount of weight), then decrease the amount of repetitions, If you increase the frequency of workouts, then decrease the duration of the workout.

The last phase of healing is the “Remodeling Stage”. This usually occurs around weeks 10 through 16. This stage of healing is when the fibers of the muscles are ready to be utilized in a Sport Specific manner. Some people use isokinetic/isovelocity machines (treadmills, stair-stepper’s, etc.), others go to the actual sport training. Remember: Always ease yourself back into re-entry training and use the following as your guidelines, common sense, pain tolerance, and doctor’s advice if under a doctor’s care.




UNDERSTANDING SOFT TISSUE INJURIES


When I look back over the last 20 plus years of being involved in Athletic Injuries I would say the most common thing I alleviate is “fear”. The fear of, “Is this injury career ending?” or “Is this injury going to take me out for the season”, or “Is this a simple injury?”. I hope that this article will answer some of those questions.

I have often thought of authoring a book and calling it “1001 Ways On: How – Not – To – Do - It”. If, as health-care providers, we would simply preface our statement with, “Based on our current research ….” or, “Based on my personal experience …” we would probably gain a lot more respect. Instead, we suffer the continual embarrassment of acting like authorities and having new technology prove otherwise. With this in mind, I would like to share this article entitled, “Understanding Soft-Tissue Injuries”. This is based on both my personal experience as a sports chiropractor for the last 20 years, of which the last 4 years spent as Director of Doll Repair /chiropractor for the Los Angeles Derby Dolls.

Since there is about as much controversy over the understanding and treatment of the body as there is in present day politics, I will do my best to stay within the areas of agreement between all disciplines. Please keep in mind that we are talking about most people and the “atypical” patient can and does walk into our office on a daily basis.

In understanding the mechanics and healing process involved with soft tissue injuries, I think it best to start with defining soft vs. hard tissue injuries. The easiest way to make this distinction is hard tissue is bone. Everything else is soft tissue. This includes, muscle, tendon (attaches muscle to bone), connective tissue (cartilage, ligaments (attaches bone to bone), fascia, joint capsules), bursas, arteries, veins and capillaries, organs and brain. Some injuries to the soft tissue will heal faster than others such as minor bruises or “track rashes” as they mostly affect the outer or superficial layers of the skin and its blood supply, or simple muscular strains, as both these areas are rich in blood supply. Other injuries may take quite some time to heal such as, more complex strain’s to the muscle in which there is a partial or complete tear, or damage to the ligaments and other connective tissues where there is a relatively poor blood supply.

When it comes to muscle and ligaments, we have classified damage into 3 categories based on the extent of damage. We call this damage a sprain, a strain, or both a sprain/strain. A “sprain” is an overstretching or tearing of the ligament, whereas a “strain” is an overstretching or tearing of muscle and/or tendon. We can however, “strain” a muscle through overuse or what we call a “repetitive trauma”. This is why it is important to have an understanding of exercise workouts and how to avoid overusing a muscle or muscle group. The three classifications of the sprain/strain component are as follows: Grade I: Is a “simple” sprain/strain, and usually is an overstretching or what we refer to as a “fraying” of the muscle fibers. Grade II: is a more complex sprain/strain. This involves a partial tearing of the muscle and/or ligament. Grade III: is the most complex sprain/strain. This involves the complete tearing of the muscle and/or ligament. In all three cases of sprain’s there will also be accompanying tearing of little arteries, veins and capillaries which will cause bleeding to occur in the area. Many times this will show up as bruising or discoloration in the area of the injury. The bleeding is an important part of the healing process as it is what will form the “scab” or blood clot to knit the tear back together.

Speaking of blood clots, this might be a good time to address another type of injury commonly seen with Roller Derby athletes; the ever-popular “hematoma”. The bruise that elevates like someone placed anywhere from a golf ball to a grapefruit under your skin. Most the time these go away with time, massage, heat and ultrasound, but sometimes if they are not treated properly they can harden and calcify in the muscle creating a painful condition we call Myositis Ossificans. Roughly translated, this means inflamed muscle tissue which is turning to bone. We will talk about this condition and the treatment for it in an upcoming article.

Regardless of the injury, whether it is hard or soft tissue, the following three stages of healing must occur in order to achieve full recovery. The first stage is known as the “Inflammatory” stage. Inflammation is defined as, “redness, heat and edema (swelling)”. The inflammatory stage usually lasts 2-3 days or 48-72 hours and usually has the following characteristics: Redness, Heat, Swelling, Decreased Movement or Ability to Contract the Muscle, Discoloration around the Injury, and, of course, Pain. As previously mentioned, with any injury, there is the tearing of blood vessels/capillaries. During the first 24 hours the blood vessels are closing off the bleeding to the area and forming a “clot” or “callus” around the injured tissue. This process is necessary for the “knitting” of the injured tissue. It begins the next phase known as the “Repair” phase.

In the Repair phase, new blood vessels are being created. The same tissue as the original tissue is being reproduced, and collagen fibers, aka scar tissue, are being laid down across the injury in all directions. Unfortunately, with muscle, the repaired area loses some or all of its elasticity (stretch). There are various forms of soft tissue therapies that address this. Many of which can return a great deal of the stretch back to the muscle. The repair phase usually starts within 48 hours of the injury and can last up to 6 weeks depending on the extent of the injured area.

The last phase of the healing process is known as the “Remodeling” phase. The collagen fibers have stopped being laid down or are minimally being laid down. This is when the newly formed tissue has the ability to start strengthening. As the increased demands or stress loads are placed on the repaired tissue, the fibers will start to align themselves for maximum strength. There are several theories as to how to maximize this. Cyriax, an orthopedist in the 1930’s, came up with what we call “transverse” or “cross” friction massage. This technique breaks down the fibers of the scar tissue in all directions. Most myofascial release techniques tend to go only in the direction of the fibers. Their understanding is, one is tacking down the fibers in the direction of the original fibers and breaking down the other more binding fibers. I personally, use my intuition and may use either cross fiber or aligned fiber approach. I do feel that regardless of the approach, it is crucial to stretch the muscle after it has been worked on. The stretching will help lay down the fibers to determine the maximum tensile strength of the fiber.

The athlete usually starts some type of rehabilitation program during the repair phase. This consists of range of motion, resisted range of motion, balance, neuro-muscular re-education (band work/ball work), stretching. In general, the athlete prepares for the re-entry into their training and sport. This is dependent on several factors: pain, severity of injury and of course if there is a doctor-involved doctor’s advice. By the time the athlete is through with the Remodeling phase they are ready to start the Re-Entry to Training period.

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