Top 10 Tips for Migraines!
- Manual Therapy
Spinal manipulation is a useful tool in migraine prophylaxis. One study demonstrated a “significant reduction” of migraine intensity in almost half of those patients receiving spinal manipulation. Nearly ¼ of migraine patients reported greater than 90% fewer attacks. (11) Spinal manipulation has demonstrated similar effectiveness but longer-lasting benefit with fewer side effects when compared to a well-known and efficacious medical treatment (amitriptyline). (11,12,13,14)
A Harvard study found that SMT significantly reduced migraine days as well as pain intensity. (52) And SMT is safe; a study to define adverse events following chiropractic spinal manipulation for migraines found that “adverse events were mild and transient, and severe or serious adverse events were not observed.” (53)
Several recent studies have shown that acupuncture is another viable tool for managing migraines. (49-51,59,60)
- Eat Smart & Maintain an Ideal Weight
Dietary fats trigger the synthesis of prostaglandins which are known migraine triggers (19). Low-fat diets have been shown to play a role in migraine prophylaxis. (20,21) Weight loss may decrease the frequency of migraine and other primary headaches (tension, cluster). (16-18) Patients on a low sodium (DASH) diet report a decrease in headache frequency vs those on a high sodium diet. (23) One new study showed that “adherence to the Harvard Healthy Eating Plate advice, particularly the reduction in carb, red and processed meat consumption, is useful in migraine management, reducing migraine frequency and disability.” (47)
- Drink Water
Increased hydration may produce subjective improvement in headache disability and intensity. (22) A study published earlier this month, showed “The results showed that the severity of migraine disability pain severity headaches frequency and duration of headaches were significantly lower in those who consumed more total water.” (48)
- Vitamin D
Vitamin D deficiency is associated with migraine attacks. (54,55) Vitamin D supplementation in a dose of 1000-4000 IU/d has been shown to reduce the frequency of migraine attacks. (55-57)
- B Vitamins
Riboflavin (Vit B2) may help prevent migraines. (26, 29-38) Dosage recommendations vary, however, the average dose used in the studies was 400mg/day. Vitamin B6 supplementation (with or without concurrent B9 and B12) has also demonstrated prophylactic benefit. (58)
- Feverfew (125mg)
Feverfew may be a useful tool for preventing migraines. (24,25,26) Dosage recommendations vary, however, the average dose used in the studies was 125mg/day.
Adding ginger to feverfew may provide relief for acute migraine. (27,28) The proprietary ginger preparation used was (LipiGesicM™ )
- Magnesium (400-600mg)
Magnesium may provide migraine prophylaxis. (26, 39-42) An umbrella review found strong evidence that “Magnesium supplementation can reduce the intensity/frequency of migraine.” (61) Dosage recommendations vary, however, the average dose used in the studies is 400-600mg/ day for the prevention of migraine in non-pregnant patients.
- Coenzyme Q10 (100mg TID)
Coenzyme Q10 may be effective in migraine prophylaxis. (26, 43-46) Dosage recommendations vary, however, the average dose used in the studies was 100mg TID.
- Melatonin (2-3mg)
One systematic review and meta-analysis concluded: “Melatonin may be of potential benefit in the treatment‐prevention of migraine in adults.” (62) Study doses varied widely (0.05-50mg), however, the typical dose used in the studies was 2-3mg, taken before bedtime.
Tim Bertelsman, DC
Do you struggle with migraines? Give us a call to see how we can help! 434-293-3800
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- Kelman L. Women’s issues of migraine in tertiary care. Headache. Jan 2004;44(1):2-7.
- Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV: The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headaches. J Manipulative Physiol Ther 1998, 21 :511-519
- Biondi DM. Physical treatments for headache: a structured review. Headache. 2005;45(6):738–746.
- Bronfort G, Assendelft WJ, Evans R, et al. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001;24(7):457–466.
- Boline P et al. Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154
- Orr SL. Diet and nutraceutical interventions for headache management: A review of the evidence. Cephalalgia. 2015 Jun 11.
- Hershey AD, Powers SW, Nelson TD, et al. Obesity in the pediatric headache population: A multicenter study. Headache 2009; 49: 170–177.
- Di Lorenzo C, Coppola G, Sirianni G, et al. Migraine improvement during short lasting ketogenesis: A proofof-concept study. Eur J Neurol 2015; 22: 170–177.
- Verrotti A, Agostinelli S, Dinelli SD, et al. Impact of a weight loss program on migraine in obese adolescents. Eur J Neurol 2013; 20: 394–397.
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- Bic Z, Blix G, Hopp H, et al. The influence of a low-fat diet on incidence and severity of migraine headaches. J Womens Health Gend Based Med 1999; 8: 623–630. 3
- Bunner AE, Agarwal U, Gonzales JF, et al. Nutrition intervention for migraine: A randomized crossover trial. J Headache Pain 2014; 15: 1–9.
- Spigt M, Weerkamp N, Troost J, et al. A randomized trial on the effects of regular water intake in patients with recurrent headaches. Fam Pract 2012; 29: 370–375.
- Amer M, Woodward M and Appel LJ. Effects of dietary sodium and the DASH diet on the occurrence of headaches: Results from randomised multicentre DASHSodium clinical trial. BMJ Open 2014; 4: 1–7.
- Pittler M and Ernst E. Feverfew for preventing migraine. Cochrane Database Syst Rev 2004; CD002286.
- Diener HC, Pfaffenrath V, Schnitker J, et al. Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention—a randomized, double-blind, multicentre, placebo-controlled study. Cephalalgia 2005; 25: 1031–1041.
- Holland S, Silberstein SD, Freitag F, et al. Evidencebased guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78: 1346–1353.
- Cady RK, Schreiber CP, Beach ME, et al. Gelstat Migraine (sublingually administered feverfew and ginger compound) for acute treatment of migraine when administered during the mild pain phase. Med Sci Monit 2005; 11: 65–70.
- Cady RK, Goldstein J, Nett R, et al. A double-blind placebo-controlled pilot study of sublingual feverfew and ginger (LipiGesicTM M) in the treatment of migraine. Headache 2011; 51: 1078–1086.
- Maizels M, Blumenfeld A and Burchette R. A combination of riboflavin, magnesium, and feverfew for migraine prophylaxis: A randomized trial. Headache 2004; 44: 885–890.
- Smith C. The role of riboflavin in migraine. Can Med Assoc J 1946; 54: 589–591.
- Boehnke C, Reuter U, Flach U, et al. High-dose riboflavin treatment is efficacious in migraine prophylaxis: An open study in a tertiary care centre. Eur J Neurol 2004; 11: 4750477.
- Schoenen J, Lenaerts M and Bastings E. High-dose riboflavin as a prophylactic treatment of migraine: Results of an open pilot study. Cephalalgia 1994; 14: 328–329.
- Di Lorenzo C, Pierelli F, Coppola G, et al. Mitochondrial DNA haplogroups influence the therapeutic response to riboflavin in migraineurs. Neurology 2009; 72: 158891594.
- Sa´ndor PS, Afra J, Ambrosini A, et al. Prophylactic treatment of migraine with beta-blockers and riboflavin: Differential effects on the intensity dependence of auditory evoked cortical potentials. Headache 2000; 40: 30–35.
- Schoenen J, Jacquy J and Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis: A randomized controlled trial. Neurology 1998; 50: 466–470.
- Nambiar N, Aiyappa C and Srinivasa R. Oral riboflavin versus oral propranolol in migraine prophylaxis: An open label randomized controlled trial. Neurol Asia 2011; 16: 223–229.
- Condo` M, Posar A, Arbizzani A, et al. Riboflavin prophylaxis in pediatric and adolescent migraine. J Headache Pain 2009; 10: 361–365.
- Markley HG. Prophylactic treatment of headaches in adolescents with riboflavin. Cephalalgia 2009; 29(Suppl 1): 100.
- Facchinetti F, Sances G, Borella P, et al. Magnesium prophylaxis of menstrual migraine: Effects on intracellular magnesium. Headache 1991; 31: 298–301.
- Ko¨seoglu E, Talaslioglu A, Go¨nu¨l AS, et al. The effects of magnesium prophylaxis in migraine without aura. Magnes Res 2008; 21: 101–108.
- Esfanjani A, Mahdavi R, Ebrahimi Mameghani M, et al. The effects of magnesium, L-carnitine, and concurrent magnesium-L-carnitine supplementation in migraine prophylaxis. Biol Trace Elem Res 2012; 150: 42048.
- Peikert A, Wilimzig C and Ko¨hne-Volland R. Prophylaxis of migraine with oral magnesium: Results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia 1996; 16: 257–263.
- Rozen TD, Oshinsky ML, Gebeline CA, et al. Open label trial of coenzyme Q10 as a migraine preventive. Cephalalgia 2002; 22: 1370141.
- Sa´ndor PS, DiClemente L, Coppola G, et al. Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial. Neurology 2005; 64: 713–715.
- Hershey AD, Powers SW, Vockell AL, et al. Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraine. Headache 2007; 47: 73–80.
- Altamura C, Cecchi G, Bravo M, Brunelli N, Laudisio A, Caprio PD, Botti G, Paolucci M, Khazrai YM, Vernieri F. The Healthy Eating Plate advice for Migraine prevention: an interventional study. Nutrients. 2020 Jun;12(6):1579. Link
- Khorsha F, Mirzababaei A, Togha M, Mirzaei K. Association of drinking water and migraine headache severity. Journal of Clinical Neuroscience. 2020 May 20. Link
- Chen YY, Li J, Chen M, Yue L, She TW, Zheng H. Acupuncture versus propranolol in migraine prophylaxis: an indirect treatment comparison meta-analysis. Journal of neurology. 2019 Aug 21:1-2. Link
- Vázquez-Justes D, Yarzábal-Rodríguez R, Doménech-García V, Herrero P, Bellosta-López P. Analysis of the effectiveness of the dry puncture technique in headaches: systematic review. Neurology. 2020 Jan 13. Link
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- Patel U, Kodumuri N, Malik P, Kapoor A, Malhi P, Patel K, Saiyed S, Lavado L, Kapoor V. Hypocalcemia and Vitamin D Deficiency amongst Migraine Patients: A Nationwide Retrospective Study. Medicina. 2019 Aug;55(8):407. Link
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- Xu S, Yu L, Luo X, Wang M, Chen G, Zhang Q, Liu W, Zhou Z, Song J, Jing H, Huang G. Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine without aura: multicentre, randomised clinical trial. BMJ. 2020 Mar 25;368. Link
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- Liampas I, Siokas V, Brotis A, Vikelis M, Dardiotis E. Endogenous Melatonin Levels and Therapeutic Use of Exogenous Melatonin in Migraine: Systematic Review and Meta-Analysis. Headache: The Journal of Head and Face Pain. 2020 Apr 30. Link
While things are slowly opening back up around here after a two-month quarantine, it looks as though gyms and fitness centers will be among the last things to return. And for many of us, it will take a long time before we’re comfortable exercising in an enclosed space with a bunch of heavy-breathing strangers. With that in mind, many of us have taken up running – one of the best full body and cardiovascular workouts out there, and one that can be done literally anywhere and requires nothing but a solid pair of shoes.
Running is incredible. I am of the opinion that human beings WERE indeed “born to run” – we are built for it. It strengthens almost every muscle in the body, it contributes to a robust and durable skeleton, it will quickly develop your cardiovascular fitness; and it’s fun. Joyful. Freeing.
However, it is also a lot of impact. With each step, running imparts forces up your foot and leg that are FIVE TIMES YOUR BODYWEIGHT. That’s a LOT of force. And for this reason, most individuals need to progress into running slowly in order to avoid injury. All you need is a plan (and some self-honesty), and it IS possible to build your running volume over time without sustaining an injury.
Step 1: Get Assessed.
For those of you without pain and without a history of lower body injury, you can *probably* skip this step, and add some jogging into your routine in a systematic fashion (more on that in a bit). But, if you are coming off an injury and/or having some pain, it’s best to get checked out by a professional. Whether you decide to see a physical therapist, a chiropractor, a PA or a physician is up to you – but make sure they have experience in working with runners. Please note that having some pain doesn’t mean that you can’t start running (especially if your pain is unrelated to, or even relieved by, physical activity) – but it’s safest for you to get a professional opinion first.
A sports physical therapist will be able to perform a running readiness screen, which includes testing your range of motion, strength, stability, and power output to make sure your muscles, tendons, and bones are up for the task. Additionally, if you’re having pain, we can help determine which tissues might be contributing, and determine whether it’s safe for you to begin running. If it’s not – no worries! We can work with you to get you to the point where it is.
Step 2: Walk
You have to crawl before you can walk…and you have to walk before you can run. If you already walk regularly, great; it’s likely you can skip this step. If not, I’d recommend starting by walking 30 minutes, 4 days per week. Gradually add time and days until you can walk 60 minutes without pain and without stopping, on at least two days per week. When you’ve reached this milestone, you can be certain that your body is ready to up the ante a bit
Step 3: Start with intervals
Where you start when you start running all depends on your fitness level and your experience in sport. If this is your first time committing to a fitness routine (which, by the way – major props and congratulations!), then running a 5k per day is not a smart way for you to begin (it will likely lead to an overuse injury). If you’re a division I soccer player who’s just graduated and looking for a new way to stay fit, however – you can probably tolerate a three mile run.
For those who are new to running, or if you’re coming off an injury, I suggest starting with intervals. These can be as short as 30 seconds of running, or as long as one minute to start with – depending on your fitness and the severity of your injury (for example, if a stress fracture has kept you out of running for 4+ months – start small. If you pulled a muscle and were out for 4 weeks, you can start with a little more). Give yourself a minute to rest in between sets, and repeat 8-10 times. That’s your run for the day.
I recommend repeating each “level” of progression three times before increasing the time spent running and decreasing your rest intervals. Almost every major sports medicine center has a “return to running” progression; Feel free to search the googles, but i feel strongly that progressions should be highly individualized based on the nature and severity of the injury and the athlete’s fitness levels.
Follow the 10% rule. When increasing your mileage, don’t add more than 10% of your total volume from week to week. For example, if you ran a total of 10 miles this week, then next week, you can add one mile to your weekly total.
Step 4: Add Volume before you add Speed. Never add both at the same time
Speaks for itself. Build yourself a comfortable base – I’d say of at least 15-20 miles per week – before you start increasing the intensity of your runs. THis allows both your cardiovascular and your musculoskeletal system to adapt to running. Both volume and intensity contribute to the overall load of running; so adding both at once will likely just overload your system and create injury. CONSISTENCY is key; don’t be afraid to build slowly, because that is your ticket to a lifelong relationship with running.
Step 5: Don’t Ignore Pain
If you should feel pain while progressing your running, a good first step is to simply take 1-2 days of complete rest, and then resume your running intervals at the level below where you were when you felt the pain. This is going to look different on every program, but for example: if you were running for two minutes, walking one minute and felt pain, then you would, after rest, initiate running at run 1: walk 1, a level below. If you’re still having pain after a few days rest and dropping it down a level, now’s the time to call your PT or physician.
Remember that any time you push your body’s limits, it’s going to respond by pushing back a little. Some aches and pains here and there are a normal part of life for a runner. I don’t want you to think that every little niggle requires medical attention. However, pain that is persistent and prevents you from finishing your runs or forces you to change your gait, definitely warrants a workup.
If you have questions, or want a personalized plan for building your running volume after an injury or time off (or for the first time!), don’t hesitate to reach out to Dr. Wason, our sports specialist: [email protected]
This started as a blog on “how to keep training during quarantine”. Which is an important topic, especially because it seems as though this is how life is going to be for the time being. But as I was writing, this is what came out instead. There are questions I need to answer, thought patterns I need to shed light on, and reassurance that needs to be given….so here it is.
“Training looks different for me now and I’m scared I’m going to gain the “COVID-19 Pounds that everyone keeps joking about”
I have several responses to that. For one, it goes without saying that if the worst thing that happens to you during this pandemic is that you pack on a few extra pounds, consider yourself very lucky. I would much rather gain weight than get sick and die, or see my loved ones get sick and die. I don’t think there’s anyone who doesn’t truly feel that way deep down. In the grand scheme of things, this is an incredibly scary and unprecedented time, and if you need an extra snack or two to cope with it? There’s nothing wrong with that. No one is judging.
That being said, being worried about your weight and fitness when your entire routine has been upended by the universe does not make you a bad person. If you are a female of any age, any background, any shape, size, activity level – you’ve had diet culture forced down your throat since the day you were born. You’ve most likely been made to feel, your whole life, that your body is inadequate and that it must be small to be “worthy”. We all have. I don’t know a single woman who’s somehow escaped that message. Men too, for that matter. If you find yourself freaking out a little extra about your weight, it doesn’t make you selfish and uncaring about the rest of the world – you literally can’t help it because this is what you’ve been taught by society to value. Regardless of whether you got that message from a magazine, a movie, your mom, or your coach – it’s ingrained.
For individuals with eating disorder history, this is also an especially difficult time because many eating disorders are a form of control. There’s a LOT of things we don’t have control over right now, and it is terrifying. When the rest of your life is scary, uncomfortable, and inconsistent, focusing in on your body and food intake is a way to cope and feel like you have control over SOMETHING. Is it a healthy coping mechanism? NO, of course not – but it is effective. If you’ve fallen into this kind of pattern when stressed over midterms, deciding on a university to attend, going through a divorce or a death or a marriage…then a global pandemic is most certainly going to trigger you too, and that’s not your fault.
If this is you, I suggest forgiving yourself, showing yourself some extra love, and meeting virtually with a therapist who can help you get through this time.
On the opposite side of the coin:
It is also totally okay to continue caring about your health and fitness during this pandemic! And in that regard, I am pleased to report that the laws of physics remain the same regardless of whether you are still at work or you’re on house arrest. Physics doesn’t care about Corona. The calories in/calories out rule still applies for weight loss or weight maintenance! So, all the “covid-19 pounds” memes are truly kinda dumb. Staying at home doesn’t cause weight gain – eating more calories than you burn does (regardless of your location).
If your activity level has changed drastically and you don’t want to gain weight, eat less calories. If your activity level has increased, then rest assured that extra coronasnack isn’t doing you any harm.
Some general rules of thumb that still very much apply in this pandemic:
-Eat only when you are hungry, most of the time. Stop when you are satisfied, not stuffed
-Choose mostly whole, unprocessed foods (bonus: they’re better for your immune system than pop tarts!)
And it’s highly unlikely that your weight or fitness will be impacted by staying at home. If you are still concerned and want something more specific, I highly recommend connecting with a sports dietician – most of them do remote consults and they can put you on a plan that will take a lot of the stress out of eating. Who needs one more thing to stress about right now anyway?
As for your activity level? Keep in mind that we are all, collectively, under a great deal of psychological stress right now. Your body does not know the difference between physical stress and psychological stress so…it all adds up in the same way. Think of your stress capacity like a bucket. Both physical and psychological stress fill up the bucket, so the more emotional stress you have – like living through a global pandemic– the less room in the bucket there is for adding physical stress (workouts) – before the bucket spills over (aka you get injured or get sick).
That being said, most of us actually need to slow down with our training, rather than ramping it up. Have you noticed your legs feel heavy? Or that you wake up stiff as a board? Or that you’re sleeping way more than usual, or having more trouble sleeping than usual? That’s the stress – and those are the same symptoms as overtraining syndrome. Slow down, and your body will thank you.
If you are struggling with this quarantine in any way – with body image, with food intake, with exercise, with training for a sport, with an injury – please reach out to me: [email protected] Let’s talk, I’m happy to help you with all of the above.
WE ARE NOW OFFERING TELEHEALTH VISITS TO IMPROVE SAFETY AND ENSURE CONTINUITY OF CARE
In order to keep our patients safe who still wish to be seen in the clinic, we have established new guidelines and requests for patient care. :
1. If you have traveled outside of the country, please do not request or attend an appointment until you have surpassed the minimum 14 days of quarantine. The same applies if you have traveled to a domestic ‘hot zone’ NY, CA, LA, etc.
2. If you are feeling unwell (whether you think its allergies or not), please reschedule your appointment. No cancellation fees will apply during this precautionary timeframe.
3. If you are over 60 years of age or have any underlying health conditions, please reconsider attending your appointments at this time. You have an increased health risk associated with this virus and we would like to minimize that risk, if at all possible.
4. Upon entry and exiting our clinic, please sanitize your hands with the sanitizer located near the check-in kiosk.
5. Please be cognizant of our social distancing measures. Our waiting room allows 6ft of distancing as does our treatment area. Our providers will adhere to maintaining 6ft of distance whenever possible during your treatment.
6. We will be keeping windows and doors propped open as weather permits to allow constant air flow and to prevent our patients from repetitively touching door handles etc. Please dress appropriately as the clinic may be cooler than usual.
7. Our providers may wear masks and will be wearing gloves when performing any manual therapy on our patients.
As we remain open, the safety of our patients and staff is our number one priority. We have made changes to cleaning of the clinic space and equipment as well as to our scheduling policies during this time. Thank you for your patience and understanding during this trying time.
Abby Wambach. Golden Tate. Morgan Brian. Colin Kaepernick. Sue Bird. RGIII. Mia Hamm. Allen Iverson. Tom Brady .
What do these individuals have in common, aside from being highly accomplished professional athletes?
They were multi sport athletes all the way through high school. That means they played one sport in the fall; another one in the spring; some of them a third, still different, in the winter; and likely took summer as an off-season where they remained physically active – playing kickball with friends, jumping in the lake, riding bikes around the neighborhood – but weren’t formally training for a sport.
As a sports specialist physical therapist, parents are constantly asking me when, and whether, their child should specialize in a certain sport. I understand -when you notice that your child is good – even exceptional! – at something, you want to help them develop that as best you can, as soon as you can. You also generally have the ability to do so, with school teams, travel teams, and local leagues in abundance.
So when SHOULD a young athlete specialize in one sport? As late as possible. Here’s why.
Risk: Overuse Injury
Repetitive stress is one of the primary causes of sports-related injury. Despite how we usually consider children to be “spry” and “resilient”, they are actually much more susceptible to certain kinds of overuse injury than adults because 1) their skeletons are not fully developed and 2) they are not able to build muscle strength and hypertrophy the way adults are. When a young athlete participates in the same sport year-round, they are only developing one set of skills, one set of movement patterns; this can lead to increased risk of injury outside their sport too. Additionally, repetitive movements like pitching a baseball, bringing the shoulder through a swim stroke, or striking a soccer ball actually involve higher forces going through the body than you might think. This puts extra stress on the athlete’s still-developing muscles, tendons, bones, and especially growth plates.
It needs to be said too that the number one risk factor for sustaining a sports injury is….having had a previous sports injury! Overuse injuries, while they’re rarely a career-ender (but can be!), are in many ways setting the young athlete up for a tough ride in their sport.
The developing brain of a young athlete is not meant to focus on a singular task day after day, year after year. Quite the opposite – children and adolescents need variety in order to thrive and grow, both mentally and physically. The more specialized a young athlete becomes, the more likely they are to become frustrated and, well….burned out. Did you think burnout was just for medical students or adults working desk jobs they hate? Think again. When kids do too much of one thing, and experience too much pressure from coaches and parents, they will fold, and it is harder for them to recover than it is for adults with fully developed brains.
Burnout is a huge problem that has dire health consequences for young athletes. Involvement in sport has endless benefits, from learning how to work as part of a team to keeping a person’s heart and lungs healthy to controlling their weight. If an athlete becomes burned out by their sport at a young age, they are much less likely to ever participate in sport; and are even less likely to continue with physical activity. This puts them at risk down the road for obesity and cardiovascular health issues. You can see how this is not just a problem at the individual level, but at the societal level as well. The key to keeping young people involved in sport all through life is VARIETY.
Reward of Waiting: Athletic Prowess
You read the names I listed above. There are countless more. The more variety a child has in their athletic activity, the more comprehensive their athletic development. Athleticism is not the same thing as having skill at a particular sport. Athleticism refers to strength, power output, speed, agility, reaction time, and endurance. Sport-specific skill refers to things like refining your pitching biomechanics, honing the accuracy of your shot on goal, working on your running form, gaining confidence with tackles. Sport-specific skill, of course, is important for performing well and reaching the highest levels of a particular sport BUT, this should be built on a foundation of athleticism. Skill work is the steering wheel, athleticism is the engine. Build the engine first; and the best way to do that is variety. Running cross-country in the fall is a great way to build endurance so that you can play the full 60 minutes of your lacrosse game in the spring without needing a sub. Playing soccer in the fall helps build that sprint-endurance capacity you need for your finishing kick in the 800m spring outdoor track season. Riding bikes through the neighborhood with your buddies all summer allows you to rest and recover from a tough spring season while still keeping you active. Sport variety, with natural periods of exertion and rest, help your athlete grow from a curious child into a strong, athletic adult.
Reward of Waiting: Growing a high-functioning, well-adjusted adult.
Above EVERYTHING else, sports should be fun. This obviously goes for adults as well as kids, but it needs to be said that your child is not a small adult – they do not have the mental capacity to go to work at the same job day in and day out the way we do as adults. Think of their sport like a job; it is not hard to see how playing soccer 365 days a year can eventually come to feel like a job. Kids are meant to spend most of their time playing, exploring and having fun, and movement is one of the best ways to do that. There is no reason for any child under the age of 18 to be experiencing burnout or injury; let’s not take their childhood from them too early. I promise, it will have no detrimental effects on their ability to be a high-performing adult. Quite the opposite in fact.
If you are curious about how to optimize your child’s athletic development, reach out to our sports specialist Dr. Wason. She can answer any questions you may have, provide athletic development training sessions for healthy athletes ages 10-18, and physical therapy services for young athletes with overuse injuries. [email protected]
Have you ever experienced anterior knee pain? The likely answer is yes, and it can be quite debilitating! There are a variety of causes for anterior knee pain including patellar tendinopathy (tendonitis), chondromalacia patella, patellar tracking issues, and more serious injuries like ACL tears. This blog with focus on patellar tendinopathy.
What is Patellar Tendinopathy
So, you may be wondering how this condition starts in the first place. It is usually the result of overloading the tendon before it has time to adapt. By not allowing for a gradual increase in training load, the tendon faces more stress than it is capable of tolerating. Generally it affects the adult population ranging from 16-40 year olds, but can affect anyone if a training schedule is not properly developed. Once the condition has developed, it can take anywhere from 2 weeks to 2 months to fully resolve.
Biological signs of the injury include up regulation of cells that create the tendon, ground substance, nerves, and blood vessels. One hypothesis for why the tendon becomes painful is the in-growth of nerves and blood vessels; picture packing all of these substances into a compact area. The brain and central nervous system may also play a big role in sensitization of the tissue. Pain with this condition like serves more as a “danger signal” to allow the human to know something is happening in that area of the body, and is likely not a signal of tissue damage. Think of this as a warning sign to slow down and let the tendon adapt.
Diagnosis of Patellar Tendinopathy
Functional movements that usually become painful with patellar tendinopathy:
- Going down stairs hurts more than going up
- The deeper the squat, the more the pain
- Sitting for long periods
- Running, jumping, and walking hills hurts
Other hallmark signs of the condition:
- Pain in the front of the knee just below the kneecap
- Pain “came out of nowhere and progressively got worse”
- Recent change in training load
- No catching, locking, or giving-way
Real Life How it Happens
Now that we’ve gone through all the logistics of this condition, lets look at a real life example of how this can happen with running. Picture this: It’s winter, the weather isn’t great for running so you’ve been inside running on a treadmill. You have been consistently running 5 miles with no pain throughout 4x’s a week.
Then BOOM. March hits and its 60 degrees out with the sun shining. New shoes are unboxed and you can’t wait to get outside and hit the pavement. You start running outside with the same mileage, but now you’re running 5-6x’s for 6-7 miles a week because you can’t resist how nice its been outside. One morning you wake up to walk to work or class and you notice that as you’re walking down hill your knee is bothering you a little (nothing serious 1/10 pain). Over the next few days you notice the pain is getting a little worse (2-3/10 pain with stairs, hills, and now its even bothering you a little with running). Now you’re concerned because its starting to affect running.
So let’s break that story down and see how training may have overloaded the tendon before it was able to adapt:
- The obvious, moving from 4x’s a week to 5-6x’s a week and increasing mileage
- Moving from a treadmill which absorbs some shock to pavement
- Flat to hilly terrain
- Even to slightly tilted or cracked sidewalks
- Going from a consistent speed or cadence to one that is likely more varied
- Change in temperature
As you can see, outside of the obvious, there are a lot of other variables that need to be accounted for to allow the tendon to adapt properly. No matter the activity, it is important to allow adaptation to training volume, load, surface, or equipment. The importance of ramping-up training or allowing appropriate time for tissue adaptation can not be overstated. This is why this injury is usually more prevalent at the beginning of a sporting season or training regimen.
As always, better outcomes are seen with more timely interventions versus the wait and see method. Treatment is generally aimed at reducing pain, promoting tissue adaptation and healing, and improving proprioception in the joint and surrounding tissues. Eccentric and heavy slow resistance exercises have been shown to be the most beneficial in treating this condition and some protocols have been established. Since everyone’s tendon quality and pain levels may be different, it’s essential to ensure you are starting at the right level for your level of tissue irritability. If the tendon is stressed too much during recovery, the tendinopathy cycle may repeat itself and may become worse.
Remember, there is no established time frame for recovery, so being patient with recovery is important. The good news is that you can usually continue training during rehab, but it is best to consult your physical therapist about adjusting impact training, training load, or training volume.
Bryan Esherick PT, DPT
Anterior Cruciate Ligament (ACL) ruptures are one of the most common injuries in sport. Most occur without contact, and occur far more often in female athletes than in males. There are many ways to injure the ACL; maybe you’re a soccer midfielder who got into a 3-way tackle at practice. Maybe you’re a goalie who went to clear the ball and felt your plant leg crumble underneath you. Or maybe, if you’re really unlucky, you stepped in a pothole walking home from a game. Regardless of the scenario, when an ACL ruptures you will feel a pop, likely feel your knee “go inward”, and experience immediate swelling.
While there are several clinical tests that a physical therapist can use to determine the status of your ACL, the gold standard for diagnosis is MRI. Once an ACL tear is confirmed on imaging, the gold standard of treatment is still surgical reconstruction. Research is coming out now suggesting that some individuals can “cope” with intensive rehab, but what we see in the literature is that this only occurs for about 25% of patients who sustain an ACL rupture. If you are going to return to a high-level contact sport – and especially if you’re female and under 30 – your best bet for returning to optimal performance is a reconstructive surgery.
While it’s a common injury in sport, it’s also an emotionally difficult one; it’s likely your season will be over. Athletes will usually feel grief grief over suddenly not being able to do the thing you love, anger at watching your teammates continue to thrive and perform in your sport, and fear that you’ll never be the same again.
These are all normal feelings to have, but in excess, they’re actually going to prevent you from making a solid comeback. So, here are some steps to take to get your head back in the game, and some information for you so that you know exactly what to expect after you’re wheeled out of the operating room.
First: Know that it’s going to be okay.
While an ACL rupture is likely a season-ender, it doesn’t have to be a career-ender if you find the right orthopedic surgeon and a physical therapist who specializes in sports. How many of you watched Megan Rapinoe this year in the world cup? Did you know she tore her ACL – for the THIRD time – in 2015, and was back on the field for the Rio Olympics? . Yes it takes a long time and a lot of hard work, but know this: you WILL play again.
Second: Learn about what’s going to happen in the Operating Room.
Surgeries are scary, but the good news is that sports medicine surgeons perform this operation all the time. Choosing your surgeon is important – you want someone who is board-certified in sports medicine and who does this operation regularly. It is more than okay to ask your surgeon how many ACLs they have reconstructed! Choose your surgeon well – make sure they have LOTS of experience with this operation and make sure that they share your goal of getting back with your team – and you will be just fine. In the operating room, the surgeon will make a small incision and will first debride, or clean up, the inside of your knee. She will likely remove the torn portions of your old ACL. Then, she will take a portion of one of your tendons – either your patellar tendon (front of your knee), hamstring tendon (back of your knee) or quad tendon (just above your kneecap) and creates a “graft” by re-inserting the tendon into the joint, such that it will act like a new ACL.
Third: Get your dang knee straight!
After you wake up from surgery and make it home from the hospital, you’ll likely be sore, but it’s important to get that knee moving. Check with your surgeon about specific precautions and limitations, but in most cases physical therapy should begin 1-5 days after your surgery. The most important thing in the early phases of rehab is to regain full range of motion, especially extension. Without full range of motion, strength gains will be hard to come by. The earlier you start working on this, the less painful and difficult it will be over time!
Fourth: Train Hard.
Find yourself a physical therapist who specializes in sports rehabilitation. Your physical therapy sessions should feel progressively harder and harder, and your PT should be stressing your cardiovascular systems in addition to getting you strong. If you’re not sweating during your sessions and have mild DOMS afterward – and if you’re not eventually doing things that look and feel like your sport – find a new PT.
Lastly: Be Patient. Play the Long Game.
You’re six months out from surgery, running intervals, doing box jumps, and feeling GOOD. So…why can’t you play? The sports medicine and rehab research overwhelmingly and unequivocally shows that for every month you wait to return to play after that 6 month mark, you decrease your risk of reinjury by 50% . That’s huge. Even if your ligament has healed and you’re passing your return to sport tests, the extra three months to get fitter and stronger matter so much to keeping you in the game. You can reduce your risk of re-injury by waiting until you are stronger and fitter than you were even before your injury. Your physical therapist should be guiding you there and encouraging you every step of the way.
If you have questions about how to prevent ACL ruptures, or whether we’d be a good fit for your pre- and post-operative rehab following this injury, reach out to our sports specialist Dr. Wason: [email protected]
A more accurate term for a stress fracture is “bone stress injury” (BSI). This is because bony stress injuries occur along a continuum based on how much loading the bone is being asked to sustain. When caught early, that dull ache at the front of your shin, for example, might just be what we call a stress reaction: there is edema (fluid) in the bone marrow, but no visible fracture line. If a stress reaction isn’t caught in time and/or the athlete continues to run through the pain, the bone can be stressed to the point of a partial fracture, what we call a “stress fracture”. Usually, pain with a stress fracture is significant enough that the athlete cannot continue to run through it. However, in cases where the bone continues to be loaded beyond what it is capable of tolerating, a stress fracture can widen and deepen and eventually progress to a complete break in the bone. Again, this is rare because most athletes will voluntarily stop their training due to intolerable pain with a stress fracture.
Who gets stress fractures? Bones respond to impact. Moderate amounts of impact activity, such as walking, running, and jumping – when progressed appropriately – are actually GOOD for your bones. Bones actually cannot get strong and dense (aka, strong enough to resist fractures and stress fractures and reducing the likelihood of osteoporosis in your later years) without some impact loading. The best way to go about this – if you’re not already a runner or involved in a running/jumping based sport like basketball or soccer – is to schedule a visit with a sports physical therapist who can help create a program for you to safely and effectively load your bones.
However, when it comes to loading your bones, it’s very easy to have too much of a good thing. HIgh volumes of load, or increasing your load very suddenly, will “stress” the bone and eventually cause it to crack. Generally, stress fractures occur in athletes who run – cross country, track, marathoners, as well as running-based sports like soccer and lacrosse – and in athletes who jump. They also occur commonly when an athlete is transitioning from a nonweightbearing sport like cycling or swimming into more running. A stress fracture is typically preceeded by a significant increase in impact activity beyond what the athlete is used to.
Stress fractures can also occur in the absence of an increase in training load. However, the reason is always due to an increase in stress on the body. This can be physical stress in the form of training load, but can also be emotional/psychological stress (for example, making the transition from high school to college), or metabolic stress from not eating enough. Bones, just like muscles, need fuel to build themselves up and keep from breaking down. For more information on the relationship between energy balance and bone health, see our last post on relative energy deficiency in sport!
A clinician will usually be able to determine whether or not they suspect a stress fracture based on the patient’s history and on several clinical tests. However, imaging is necessary to rule these in or out. Despite being a bony injury, most stress fractures will NOT show up on X-Ray; MRI is the gold standard for diagnosis.
Following diagnosis, a stress fracture will usually require a period of unloading depending on severity. Stress fractures in the foot and ankle will usually require a walking boot; stress fractures higher in the leg will require crutches. THe length of time on crutches is entirely dependent on the severity of the fracture. During this time, most athletes will be allowed to cross-train in the pool (swimming or deep-water running) or on a stationary bike – again, depending on the severity of the injury.
Most stress fractures take 6-8 weeks to heal. A common misconception, however, is that once the bone is healed the athlete is clear to resume running. While it’s true that after the bone has healed, the athlete can resume LOADING the bone, this does not mean they are ready to run. With every step you run, your leg has to absorb forces that are FIVE TIMES GREATER THAN YOUR BODY WEIGHT. Starting at this amount of load will likely just lead to a second fracture.
This is where physical therapy comes in! A sports specialist will be able to design a gradual loading program for you, involving progressing walking speed and distance, improving global lower body and core strength, and eventually, progressing plyometric activity in order to guide you safely back into running. This way, you can return to your sport stronger than you left it, and with full confidence that you will not experience an injury like this again anytime soon. Additionally, a female athlete specialist (like Dr. Wason!) can help coordinate the resolution of any risk factors you may have, such as your training volume, your fuel intake,body image issues, and your menstrual cycle status (for more on how your menstrual cycle affects your bone health, see our previous post on RED-S).
If you are a runner or running athlete and you:
-have been diagnosed by a physician with a stress fracture
-have had a bone stress injury in the past and are struggling to return to training
-are having pain with training and suspect you might have a stress fracture
-just want to avoid a bone stress injury
Send an email to Dr. Kate with any questions or concerns or to set up an appointment!
Most everyone reading this has heard of eating disorders. Somewhat less of you, but still a lot, will also have heard of the Female Athlete Triad. But likely few will know what RED-S is. RED-S, or Relative Energy Deficiency in Sport, actually encompasses and expands on the female athlete triad and is essential for you to know about if you are an athlete, a parent of an athlete, or work with athletes in a coaching or healthcare capacity.
The Female Athlete Triad describes three inter-related health issues that occur specifically for female athletes when their food intake is not enough to support their activity levels. Oftentimes, this imbalance occurs due to disordered eating; intentionally restricting food intake in order to achieve leanness or small-ness which, for better or worse, can be advantageous in sports like distance running, triathlon, gymnastics. Over time, this lack of fuel triggers the body to essentially curl up in a ball and protect itself via shutting down the reproductive system. Your body will always prioritize survival over reproduction; this is why most women with eating disorders will lose their period due to low energy availability. The way this occurs is through alteration of hormone production and circulation in the body. In women, bone health is directly tied to reproductive hormone levels. Estrogen and progesterone levels are altered, which then has a cascade effect on your bone health. In sum: disordered eating leads to menstrual cycle disruption/hormone dysregulation and sad bones.
It seems fairly comprehensive, right? But it actually leaves a lot out, and that’s where RED-S comes in. This is the new term that we’re using instead of the “female athlete triad” for the following reasons:
Relative Energy Deficiency in Sport affects men too.
Men certainly don’t menstruate and don’t have the same link between bone health and sex hormone profile that women do, but they do still suffer the consequences of not eating enough. As we’ll talk about later, not eating enough can affect ALL your body systems, not just bones and reproduction. This is one of the main reasons for the change in terminology!
The “ED” in RED-S stands for “Energy Deficiency” and not necessarily “Eating Disorder”
It’s true that eating disorders are a massive problem in sport. The vast majority of women and girls will at some point and in some way, struggle with their body image and their relationship with food. However, it is also common for athletes to under-eat simply because they don’t know any better. Young women and girls are especially unaware of how many calories they actually need. I blame diet culture for this – many of us are lead to believe through the media that 1500 calories a day are sufficient. In reality if you’re active and/or still developing, it most definitely is NOT appropriate. Most female athletes need between 2,000-3,000 calories per day. (If you are curious about your own personal needs, I encourage you to get in touch with a Registered Dietician). As an example, consider the following scenario:
You’re a college freshman and you’re trying to balance 1) being a member of a sports team 2) classes and homework 3) finding your way around campus 4) making friends 5) being homesick 6) oh and the dining hall doesn’t have anything you like, ugh.
It isn’t hard to see how this young woman – and thousands just like her – are not getting enough calories. And it doesn’t mean she has an eating disorder. So that’s another reason for the change in terminology – being energy-deficient isn’t always due to restriction. This is where healthcare providers and coaches can play a huge role in educating girls and young women about what they actually need to consume and how to do so conveniently!
RED-S affects MUCH MUCH MORE than bones and sex hormones
Low energy availability affects every system of the body. It absolutely can lead to low bone density which increases an athlete’s risk of stress fractures. It will also shut down a woman’s menstrual cycle because with limited resources the body needs to choose between reproduction and survival. However, it also has effects on:
Mental health: poor regulation of serotonin/dopamine = bad moods, irritability, lashing out, and increased feelings of depression and anxiety. Your body needs fuel to appropriately store and release hormones too!
Energy levels: The term “energy deficiency” says it all. Feeling sluggish, foggy, sleeping excessively or having difficulty with sleep are all potential symptoms of RED-S. Additionally, athletes will often struggle to complete workouts or will feel that a volume/intensity of work that has been typical for them has suddenly become challenging
Cardiovascular health: Your heart is a muscle, and it uses carbohydrates and fats for fuel just like all the other muscles of your body. Without enough fuel, your heart muscle will not be able to work as efficiently. This can change the electrical conductivity of the heart leading to things like arrhythmias – which will disqualify an athlete from participating in sport. It also leads to feelings of fatigue – workouts suddenly feel hard because the heart is having to work with less fuel!
Your musculoskeletal system: If you’re not putting in enough fuel to allow your body to recover, it breaks down more easily. This is true
In summary, Relative Energy Deficiency in Sport is the new term we’re using to describe when athletes of all genders don’t eat enough to support their activity.
Our bodies are built to do what our brains ask it to do. If you ask it to move in a particular way, it will do it, but it may not always be exactly how we imagined it. Think about watching people pick up an object from the ground: There are many different ways to do this, and your body will choose the best one suited for you. If you read part one of this series, you should now have a better understanding about what motor control is. Here in part 2, we’ll discuss how motor control may cause and be affected by pain.
Issues in motor control may be a likely culprit if part of a certain motion is pain free but other parts painful. From an observational standpoint, issues are usually evidenced by “jerky” or “ratchety” motion: Compensation patterns are also usually noted like moving from the hips when asked to flex in the lower back. Not everyone with these issues present with all of these characteristics, but it is likely to see at least one if this is contributing to the painful experience.
Now that you know a little more about what motor control is and how to spot it, you may be wondering how it can lead to pain and dysfunction. Depending on who you ask, you may get a different explanation! In my opinion, there are two different schools of thought on the subject: Pain causing motor control issues, or motor control issues causing pain. I’m personally a believer that motor control issues are caused by pain via a complex interplay of different systems.
We know that pain can affect a lot of things including activity level, social interactions, movement, mood, etc. When pain is present in an area it begins to affect proprioception and muscle activation, both of which are required for pain free control of movement. When the muscles and nervous system aren’t communicating optimally, pain and movement difficulties begin to occur. This leads to a cyclic pattern between pain and movement. Rather than put it in words, there is a graphic below that describes this cycle. Keep in mind, the arrows can go in both directions on the graphic, and one does not necessarily cause the other. So although it may be a case of which came first, the pain or the motor control issue, either pathway leads to a continuous cycle of pain and discomfort and needs to be disrupted with intervention.
So although motor control exercises should be a component of treatment in some conditions, it is not the magical cure to any musculoskeletal issue. It should be combined with other treatments including active therapeutic exercises and manual therapy. When we work with clients that we believe have issues with motor control, we focus on performing slow purposeful movements. It’s like taking baby steps and learning how to walk, or move your shoulder, properly again. Purposeful thoughtful movement allows the nervous system to begin communicating with the muscles more efficiently. Overtime, this will begin to improve motor control and break the pain cycle above.
Unfortunately, without a specific injury or examination, we cannot go into much more detail than that in terms of treatment. Please reach out if you have any questions on this topic and check out our instagram and facebook for some motor control exercises you may be able to do if you are experiencing pain.
Bryan Esherick PT, DPT