ABOVE ALL ELSE, GET THAT KNEE STRAIGHT
By Mark Salamon, August 1, 2018
Total knee replacements are one of the most common surgical procedures in America. Knees wear out just like tires on a car, so if you live long enough, you will probably need a knee replacement. So I thought it would be a good idea to prepare everyone out there for this impending event.
The hardest part about knees is that most of them get very tight, so the most important aspect of rehabilitation is gaining range of motion. Since the knee only moves in two directions, you only have to worry about two motions: bending (flexion) and straightening (extension). Most people tend to focus on bending, and that is important. But most people don’t know that straightening is actually more important, especially in the early stages of rehab.
The soft tissue in the back of the knee tends to tighten down very quickly, and if it is not stretched early after surgery it can harden like cement. This is called a knee flexion contracture, and can happen not only after a total knee replacement, but after any knee surgery. In fact, it can happen even without surgery to an injured knee or a knee with gradually worsening arthritis.
A knee that doesn’t fully straighten essentially makes that leg shorter than the other leg, which can cause many other problems including ankle, hip, and back pain. Conversely, a knee that doesn’t bend all the way can still function adequately for most activities. Eighty-five percent of normal bend is sufficient to walk and go up and down stairs, so attaining full flexion is not as important as attaining full extension. Bending will also continue to improve slowly over time for many months, so you don’t have to get it right away. But as I said before, if you don’t get the knee straight within the first week or two, it will scar down and become permanent.
The best time to stretch is before surgery. Many doctors will refer patients for a month of physical therapy to get them ready for their knee replacement. The more range of motion you have before surgery, the easier it will be to regain that motion after surgery.
The best time to stretch extension after surgery is immediately. By this I mean the minute you wake up from anesthesia. You may wake up and find that a well-meaning nurse has put a towel-roll under your knee to make you more comfortable. This is one of the reasons why knees get stuck in that bent position - it feels better. It hurts to push it straight, but it must be done. So take that towel-roll out from under your knee, put it under your ankle, and start pushing your knee as straight as you can get it. You may find that it is hard to get the thigh muscle to contract, and it will feel like you don’t have the strength to push it straight. If this happens, use your hands. Hold the stretch for a count of ten, relax for a second, and repeat this twenty times. Do this every thirty minutes or so.
If your physical therapist comes in the room and finds you doing this, you will probably be named Patient of the Year.
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TO CORRECT POSTURE, TRAIN THE BODY AND THE MIND
By Mark Salamon, July 1, 2018
Poor posture is one of the leading causes of headaches, neck pain, upper back pain, and your mother nagging you. It is also something that physical therapists have been trying to correct since humans started standing erect. Poor posture can make it more difficult to rehabilitate neck and shoulder injuries, and can also progress to more serious conditions such as compression fractures in the vertebral bodies.
When the head and shoulders come forward, the muscles in the chest and front of the shoulders become tight, and the muscles in the upper back become stretched out and weak. So from a purely mechanical standpoint, correction exercises focus on stretching the muscles in the front and strengthening the muscles in the back. But that is only half the battle. Actually, it is only about ten percent of the battle, because ninety percent of posture is habit. You can have all the strength and flexibility in the world, but as soon as you stop thinking about it, you will fall back into the position that has become habitual.
The only way to correct a habit is through repetition, so in addition to stretching and strengthening exercises, I recommend utilizing something known as the “chin-tuck” position. This involves gliding your head straight back without looking up or down. When done correctly, it feels like you are tucking your chin in towards your neck. This maneuver puts your head in the correct position over your spine, and everything else falls into place. It takes little muscular effort to hold this position because your head is balanced over your spine. When your head is forward, the neck muscles have to contract to keep your head from falling forward. This is one reason poor posture causes neck pain.
It is possible to force good posture by pulling the shoulders back, but this requires the muscles to work harder and you will fatigue. So the chin-tuck is much more effective. It can be used as an exercise by holding the position for a count of ten and repeating ten times. It can also be used to break the habit in other ways. One way is to set your alarm to go off once every hour throughout the day, and this will be your reminder to get into that chin-tuck position and keep it for as long as you can remember to hold it. If your short term memory is anything like mine, this will probably be about five seconds, but as time goes on and it becomes more of a habit, this will get longer and longer.
If you exercise, you can also use the chin-tuck by making it a part of every exercise you do. Just get in the chin-tuck position before starting each exercise, and hold the position throughout the exercise. This not only creates repetition, but reinforces the habit of holding the position while doing other activities.
Breaking a habit is not easy, but with persistence and repetition, you can do it. Strength and flexibility are important, but it will not work unless you train your mind as well.
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TO PREVENT BALANCE PROBLEMS, DON’T FORGET ABOUT STRENGTH
By Mark Salamon, June 2, 2018
One of the most important jobs of a physical therapist is helping people prevent falls. The older you get, the more important this becomes. Bones become brittle and falls can be devastating. In fact, studies of older patients show that about twenty-five percent of those who fall and break a hip die within a year. (1)
Balance problems can be caused by many things, from complex inner ear issues to strokes to brain injuries. Many of these causes are beyond the scope of a quick discussion. But there is one very straightforward factor that I would like to address because it often gets overlooked, and that is strength. Several studies have shown a correlation between strength and balance, particularly those involving the elderly and those with conditions such as Parkinson’s disease. (2) (3) (4) But even high school athletes have been shown to have diminished balance when the core muscles are weak. (5)
Strength of the legs and core are especially important. The core consists of the muscles of your low back, which wrap around to the stomach, as well as the sides of the hips and the buttocks. These muscles are like the trunk of a tree. They are the foundation that gives you stability. Strength of the leg muscles is also critical, especially if one leg is stronger than the other. If you have ever injured one knee or ankle and had to limp around for a while, you may have experienced this effect on balance. It throws you off and makes it much easier to fall. So for the average person who is lucky enough to be getting up in years, a good strengthening program can significantly decrease your chances of falling.
If you happen to have a medical condition that causes dizziness, you should see a therapist who specializes in vestibular rehabilitation. There are specialized exercises and activities that are specific to various diagnoses that can improve balance and decrease the risk of falling. And if you fall into this category, it is even more important to strengthen the core and legs, because weakness can compound your already high risk of falling.
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BE CAREFUL WITH EARLY MORNING WORKOUTS
By Mark Salamon, April 1, 2018
Since the dawn of time, celebrities have been inspiring people to spring out of bed at ridiculous hours to jump start their day with insane workout routines. From John Quincy Adams skinny dipping in the Potomac to Rocky chugging raw eggs, famous workaholics everywhere have set heroic examples for the average person to follow.
So I thought I’d add my story to the mix and describe my morning routine for my fans to emulate. My alarm goes off at 5:15 am and I immediately perform an exercise that involves rolling on my side, sitting up on the side of my bed, and attempting to stand erect. This is followed by a pre-dawn walk of about 8 feet where I stop and attempt to hold the erect standing posture for whatever length of time it takes me to urinate. This is followed by an even longer walk to the kitchen where I perform another strenuous exercise called making breakfast. To perform this exercise safely, I make the same breakfast every day, because attempting to be creative at this ridiculous hour can result in serious injury. Also I’m lazy.
Following breakfast I perform an advanced stretching routine I like to call “putting my clothes on”. At this point my breathing and heart rate are pretty much maxed out, so before driving to work I perform a cool-down routine that involves brushing my teeth and petting the dog.
At this point I feel like a new man, bursting with energy and ready to take on whatever the day might bring. The thing I like most about this routine is that it has not yet caused serious injury. This is in sharp contrast to morning routines I used to perform before all of my brain cells were fully developed. Things like running, jumping rope, and heavy weight lifting first thing in the morning gave me the opportunity to experience first hand what it’s like to inflict serious bodily harm on yourself. I know a lot of people out there still perform early morning routines like this, and I would personally like to thank each and every one of them for putting my kids through college.
So here’s the thing. When you lay motionless for eight hours, everything slows down. Heart rate, circulation, breathing. This causes everything to get tight, like a dried out sponge. If you bound out of bed and launch into a Navy SEAL training regimen, something’s going to tear. The safest time to exercise is later in the day after the soft tissues of your body have had a chance to gradually fill up with blood and loosen up. If you really love that early morning workout, I’m not going to tell you to give it up. Just take it slow. Leave enough time for a long, gradual warm up. Or just keep the whole workout light, like mine.
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AN MRI IS NOT ALWAYS NECESSARY
By Mark Salamon, March 1, 2018
I have been getting a lot of this lately: “My doctor wants to get an MRI, but the insurance won’t cover it unless I go to physical therapy first, so that’s the only reason I’m here”. Isn’t that a great way to start a patient-therapist relationship.
The understandable next statement is, “so I’m a little nervous about this because if we don’t know what’s going on in there, how do we know if the therapy is going to damage something and make it worse?”
Valid point. If I were the patient, I’d be saying the same thing. This is happening with many diagnoses, so let me use one of the most common examples: a back injury with sciatic pain down the leg. Few things make you feel like something is really wrong like nerve pain travelling down your leg, especially when there is numbness and tingling on top of it. The obvious reason to get an MRI is to see if there is a bulging or herniated disc that is pressing on a nerve. That would be the worst case scenario.
But here is the kicker. If you got an MRI first, and it did show a large herniated disc pressing on a nerve, the next course of treatment would still be physical therapy. This is because most of the pain from this type of injury comes from inflammation of the surrounding tissues and spasm of the surrounding muscles. There are also positioning exercises that can help a bulging disc gradually move back to its correct position. But the disc itself is often not the cause of the pain. When MRI machines were first developed, they took thousands of images of people with no history of back problems to see what a normal spine should look like. To their surprize they found that about a third of all people walking around have bulging and herniated discs and don’t even know it. There are also many people with horrific nerve pain, numbness and tingling who’s MRI shows completely normal discs. So even if the MRI shows a herniated disc, it cannot tell you if that disc is what is causing the pain.
Numbness and tingling is the first symptom that you get with a little pressure on a nerve. It is very annoying and will drive you crazy, but it is not enough to damage the nerve. More pressure on a nerve will cause radiating pain, but no permanent damage. The red flag that therapists watch for is progressive weakening. That is, if certain muscles are weaker every time you come in for treatment, that means that surgery is probably needed to take the pressure off the nerve to prevent permanent damage. This is very rare, but if your therapist sees it, they will refer you back to the doctor for a surgical consult.
The vast majority of back injuries do not fall into this category, and the most important thing to know is that without an MRI, the therapist will assume the worst and not do anything that would cause further damage. This is one of the very few times that I will ever make the following statement: I actually agree with the insurance companies on this one. Why get an MRI when the results will not change the treatment? Less invasive treatments should always be done first. If physical therapy does not work, then injections are usually the next line of treatment, followed by surgery, which should always be a last resort. An MRI makes sense in these situations, because it will show the doctor exactly where to put the needle or what needs to be surgically corrected.
This also applies to many other injuries, and your doctor or therapist should explain this. But don’t be afraid to ask. If you don’t get an explanation that makes at least as much sense as the one I just gave, you may want to get another opinion.
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THE MYSTERY OF UNEXPLAINED MUSCLE PAIN
By Mark Salamon, Feb 1, 2018
Working with patients every day allows me to stumble upon things that I would never find by reading articles, and these are the things that I strive to write about here. My goal is to give you information that you would not find in a typical news feed. So here is one that got by me and my patient’s doctor.
People complain of muscle soreness all the time, especially in my clinic where I am forcing them to exercise. Ninety-nine percent of the time this is normal, but the job of a physical therapist is to detect those times when it is not normal. So my patient, let’s call him Al, was being treated for a back injury and doing very well. He had spent a couple of months with me the previous year after a total knee replacement, and did very well with that also. Midway through this course of therapy he started to complain of severe muscle soreness in his legs. He had been on a diuretic to control swelling and had gone off of it without consulting his doctor, which caused more swelling in the lower leg that had had the knee replaced. We sent him for an ultrasound to rule out a blood clot, and his doctor put him back on the diuretic which brought the swelling down.
The muscle pain, however, did not diminish, but continued to get worse. I repeatedly examined his legs and found nothing unusual, and he returned to his doctor who’s exam revealed nothing as well. His doctor continued to tell him it must be just normal soreness from exercises. But Al and I continued to be skeptical because of the level of his pain and his history of tolerating painful rehab without a problem.
This mystery was finally solved. Not by me. Not by his doctor. But by Al “talking to a buddy of mine” who told him he had the same severe pain after his doctor put him on a different blood thinner. Al had been on Coumadin for years to prevent blood clots. For some reason, his doctor decided to switch him to Xarelto, and looking back he realized that this is when the pain started.
Al went back to his doctor and explained this hunch, and his doctor said something along the lines of “oh yea, Xarelto does cause muscle pain in some people, that’s probably it”. He put Al back on Coumadin, and said it would take a few weeks for the Xarelto to get out of his system, which it did and the pain disappeared.
So the highly trained professionals were outdone by Al’s buddy. This is the down side of our constant stream of new drugs, each coming with its own list of one billion possible side effects that no one, not even the doctors, can keep track of.
I talked to several doctors after this episode and found out that severe muscle pain can be a side effect of any blood thinner, especially for people on high doses due to high risk of clot. But the following is extremely important: DO NOT CHANGE YOUR DOSE OR GO OFF YOUR BLOOD THINNER WITHOUT TALKING WITH YOUR DOCTOR. All blood thinners are a little different, and different people react to them in different ways. (1) Choosing a blood thinner and the dosage is a delicate balance between preventing blood clots and decreasing the chance of dangerous bleeding. (2) Your particular medical history, risk factors, diet, and body chemistry determine which blood thinner and what dose is appropriate for you, and working around the side effects can only be done by working with your doctor. (3) Stopping a blood thinner abruptly can cause a rebound effect, creating a high risk of a blood clot that can kill you.
So if you have severe, unexplained muscle pain, talk to your doctor. Your blood thinner may be the culprit.
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DON’T SELF MEDICATE WITH LOW DOSE DAILY ASPIRIN
By Mark Salamon, Jan 1, 2018
Last month’s tip on the dangers of long term ibuprofen use prompted some questions on the use of daily low dose aspirin to decrease the chances of heart attack and stroke. These questions are understandable since ibuprofen and aspirin are similar drugs. They both belong to the family of non-steroidal antiinflammatory drugs, commonly known as NSAIDs, so it makes sense to wonder if the dangers of one are similar to the dangers of the other.
Research is showing, however, that the risks of low dose daily aspirin are different from the risks of long term ibuprofen, and there are several upsides to daily aspirin that are not seen with ibuprofen. To review, long term ibuprofen use has been shown to increase the risk for serious stomach (1), liver (2), kidney (3), and heart problems (4) (5), weaken tendons (6), and delay healing (7). You can also develop a resistance to ibuprofen to the point where it actually causes more pain, and going too quickly can cause severe rebound pain (8).
So how does daily, low dose aspirin compare to this? Let’s start with the risk factors. The number one risk factor, as with ibuprofen, is bleeding in the stomach or GI tract (9) (10). This can have serious, even fatal consequences, so it is imperative that you consult with your doctor to make sure that you are not in a high risk group. The risk for kidney damage has been shown in elderly people (11). The risk for stroke depends on what kind of stroke you are talking about. Daily aspirin has been shown to decrease the risk of stroke caused by a blood clot, but it actually increases the risk of stroke caused by hemorrhage or bleed (12). So again, it is imperative that you consult with your doctor to find out which type of stroke you are most at risk for. If you are on low dose daily aspirin to prevent a clotting stroke, going off abruptly can cause a rebound effect and actually cause a clot (13).
Now for some potential upsides to daily low dose aspirin. Studies have shown that it decreases the chance of developing several cancers, and slow down the spread of existing cancers. These include cancer of the skin, colon, breast, and liver (14) (15) (16) (17). Again, if you have cancer or are at high risk for cancer, your physician needs to determine if the benefits of daily low dose aspirin outweigh the risks for your particular situation.
The complexity of this decision making process has made this a controversial issue. In 2014 the FDA reversed its position on low dose daily aspirin to state that is should not be done for those who have never had a heart attack or stroke (18). As new research is done, new findings will undoubtedly affect recommendations. In contrast to daily ibuprofen use, which has been shown to have no benefit, low dose daily aspirin has been shown to have a number of benefits for certain populations, but significant risks for others. If you only take one thing away from this article it should be this: do not self medicate with low dose daily aspirin. Have a long talk with your doctor to determine if the benefits outweigh the risks for your particular situation.
KEEP IBUPROFEN TO A MINIMUM
By Mark Salamon, Dec 1, 2017
Whether you are a young, highly conditioned athlete, a middle aged weekend warrior, or a grandparent pushing into the golden years, chances are you pop the occasional ibuprofen to deal with aches and pains. You may have even gone through times where you ate these things like candy. I know I have. Television commercials even promote the practice of taking them every day, basically for the rest of your life. Well I am here to tell you that there is a growing body of evidence showing that this is a very bad idea for a host of reasons.
There is well documented evidence of serious stomach (1), liver (2), kidney (3), and heart problems (4) (5) that are associated with long term ibuprofen use. This information, thankfully, has made it to the mainstream media, and many of my patients report being very cautious with ibuprofen because of these reports. But many people are unaware that you can also develop a resistance to ibuprofen.
As usual, I became interested in this topic because of my own experience. As a highly trained health professional, I feel it is my duty to do idiotic things that I would never recommend to any of my patients, like playing basketball at age fifty-three. So there have been times where I cultivated a very close and intimate relationship with ibuprofen, and here is what I noticed. If I took it occasionally, it really did help. But the more I took, the less it worked. On several occasions it got to the point where I was taking it just about every day, almost out of habit because I was so sore all the time, and it finally dawned on me that if it were really doing anything I probably wouldn’t be so sore all the time. So I would stop and feel absolutely no different, confirming that it must have stopped working.
However, if I went weeks without it, then took it once, it really did work, making me believe more and more in the resistance theory. And it turns out that research has confirmed my suspicions. Not only do people need higher and higher doses to get the same effect, but if this goes on long enough the ibuprofen can start to have the reverse effect and cause even more pain. (6) And when many of these people do go off, the rebound pain can be even worse.
If this isn’t enough to convince you to cut back, or even quit, consider other studies which are showing that ibuprofen actually reduces the breaking strength of tendons (7), has detrimental effects on the healing process after soft tissue repetitive motion injuries (8), has no effect on long term management of osteoarthritis (9), and should not be prescribed at all for the elderly because of the underlying health risks (10).
So does this mean you just have to suck it up and suffer? Absolutely not. There are many foods that have anti inflammatory properties, including blueberries, cherries, green leafy vegetables (spinach, kale, etc.), nuts, fish, ginger, green tea, red peppers, dark chocolate, turmeric, and black beans. So eat plenty of these, and cut back on foods that increase inflammation such as refined carbs (white bread, pastries), fried foods, soda, and red meat.
If you want my opinion on the most potent anti inflammatory food, it is ginger. This is based on my personal experience, and may have to do with my particular body chemistry, but it is backed up by research. (11) (12) When I make a smoothie, I will cut up a hunk of fresh ginger about a square inch in size and throw it in there. For me, this works as well as taking ibuprofen. Ginger is also a powerful blood thinner, so if you have any bleeding disorders or are already on a blood thinner (even daily aspirin), make sure you talk to your doctor about ginger before taking it.
Again, the health risks of ibuprofen apply to long term use. There is nothing wrong with an occasional ibuprofen if you have a killer headache or just decided to get up one morning and run the Ironman Triathlon. But my advice is, keep it to a minimum.
DON’T BE AFRAID TO CUT OUT GLUTEN
By Mark Salamon, November 1, 2017
It's hard to find a more controversial topic than gluten sensitivity. Full blown gluten intolerance, or Celiac disease, is a well known, inherited condition where even a small amount of gluten can cause severe symptoms and long term damage. But many people who don’t have Celiac claim that gluten causes them to suffer a wide range of gastrointestinal symptoms that disappear when gluten is removed from their diet. Many of these people have come up against a medical establishment that has not taken their reports seriously. Many physicians still insist that there is no such thing as gluten sensitivity without Celiac disease, and that going off gluten has no effect and can actually be harmful if you don’t have Celiac. Some have even accused patients of latching onto a fad perpetrated by celebrities.
This is a classic case of doctors not listening to their patients. Don’t get me wrong, research is important, and medical practice must be driven by evidence. But research is an ongoing process, and many medical professionals fall into the trap of insisting that things that have not yet been proven are false. The fact is, there are many things that have not yet been proven that are absolutely true, and when a large number of people are reporting something anecdotally, we should take their reports seriously as a signal that maybe more research should be focused on that particular topic.
This research is actually being done, and current studies are showing conclusively that gluten sensitivity without Celiac disease is real. (1) (2) (3) Despite this, I continue to read reports of doctors advising people without Celiac that going off gluten is not only useless, but potentially harmful. As a clinician in a busy facility, I have overheard patients talking about these types of headlines enough times to know that they are indeed paying attention only to the headlines. Most of them don’t read the full articles, and even when they do, the underlying evidence for the headlines are hard to find among the hype. So let me cut through the BS. There are two rationales given by doctors who advise that gluten free diets can be harmful. The first is that many prepackaged gluten-free products are higher in fat, sugar, and calories than their gluten-containing counterparts. (4) The second, and this kills me, is that since many breads and cereals are high in fiber and fortified with added vitamins, those who cut them out of their diet will not be getting enough fiber or vitamins. (5)
This is why the United States of America spends the most on healthcare and has the worst outcomes of all the industrialized nations of the world. I have a radical idea. Maybe these physicians should be telling people to get their vitamins and fiber BY EATING MORE FRUITS AND VEGETABLES.
The following is what we went through with our daughter. I know she is one person, but believe me, she is not alone. She had major digestive problems as she was growing up, to the point where she was afraid to eat because of how sick she would get. We had her seen by many specialists, most of whom treated us like we were crazy. At one point the family doctor noticed that she was not growing, so we saw more specialists. She was finally diagnosed with underactive thyroid and was put on levothyroxine.
Since she was still a growing child, we saw her pediatric endocrinologist every three to six months to check her levels and adjust her dosage. We wanted to know why she had an underactive thyroid, but were told that there is no answer. We had allergy testing done, which revealed that she was allergic to eggs. Cutting these out helped her digestive issues somewhat, but she continued to need the thyroid medication. We did a lot of reading and asked our doctor about the link between gluten sensitivity and underactive thyroid. She told us that there were a few anecdotal things written on this, but no definitive studies. Since it had not been proven yet, we got the feeling that she did not even want to talk about it. It was almost as if she was not allowed to talk about it.
Despite this, we decided to try taking her off gluten. From one day to the next, her digestive issues cleared up dramatically. The stomach cramps, nausea, diarrhea, ninety-five percent gone practically overnight. Then a strange thing happened. Every time we saw the endocrinologist, her blood tests showed that we could cut back on the thyroid medication a little bit. This went on for a couple of years before, to our doctor’s amazement, she no longer needed the medication. Her thyroid was functioning normally.
Just to clarify, people who go on levothyroxine generally never go off of it. It is a lifelong medication for a chronic condition. Our doctor, who by the way is a very nice and caring woman, was thrilled the day she told us our daughter no longer needed this medication. I couldn’t help thinking to myself, “I’m glad you are so happy, but this has nothing to do with anything you did”. I’m not even saying this is her fault. It is how doctors in America are trained. They learn how to treat things with drugs. Getting to the bottom of “why” is almost never part of the equation.
So my advice is this. If you eat a healthy diet with a lot of fruits and vegetables, then there is absolutely nothing harmful about going off gluten, and there is a very good chance that it will help you. It does not hurt at all to try.
And by the way, the other five percent of our daughter’s digestive problems disappeared when she decided to go vegan. That’s a topic for another article.
KNOW YOUR OWN PSYCHOLOGY
By Mark Salamon, October 1, 2017
The reason many people fail in their attempts to follow an exercise routine is that they ignore one of the most important factors: their personality. Willpower will take you through a few weeks at most, but if your routine does not match your psychology, you are doomed to failure. For example, if you are not a morning person and you decide to muscle yourself out of bed every day at 4:30 to go running, I give you about two weeks.
One of the most important aspects of personality to consider is whether you are a person who likes routine or variety. Some people like the idea of doing the same workout every day. They don’t want to think about it, they just want to roll out of bed, run their three miles, and be done with it. Other people would rather hurl themselves out a window. They would be bored to death doing the same thing every day, and would rather have some variety to keep it interesting.
Figuring out which type of person you are is not always that easy, because many people are a combination of both. I am one of them. I have come up with many different workouts over the years, and when I try one that I really like, I always think, “this is it, this is the perfect workout, I’m just going to do this until I die”. And I do. Well, I do it for two weeks and then I’m so tired of it that I would rather have diarrhea for the rest of my life than do that workout one more time.
So figuring out which type of person you are is critical. But for those of you who are wired to do the same routine every day, here’s the turd in the punch bowl. Doing the same thing every day is actually not as good for you as mixing it up. I know, I’m sorry! I built you up just to pull the rug out. But all is not lost. There are ways to work variety into your psychology. I’ll use runners as an example, because many runners tend to be routine oriented. They don’t want to hear about all this other stuff. They just want to go out and run. The problem is, running is a repetitive motion. Doing the same motion over and over can cause a lot of stress on tissues. To appreciate this, hit yourself lightly on the forehead with the palm of your hand. Feels fine right? But imagine doing that a million times in a row. Not a good idea.
Running also works only certain muscles but not others, which can lead to muscle imbalances. And it does nothing for flexibility, so many runners become tight. So if you are a runner, and you want to keep a set routine, there are several options for working in a few strengthening exercises and stretches without having to reinvent what kind of workout you are going to do every day. And this doesn’t have to be anything extensive. A couple sets of push ups, body squats, and pull ups, for example, is enough to work all the main muscle groups to avoid imbalances. And a quick stretch of the hamstrings, calf, quads and hip flexors can be done in five minutes.
One option is to work these into your routine every day. For example, you stretch, then run, then push ups, pull ups, squats. Same routine every day. Or you could alternate days. One day you run, the next day you stretch and strengthen, same cycle every other day. You could even get away with stretching and strengthening two days a week and running five. The possibilities are endless. A little thought and planning is required at the beginning, but once you have it down, then you don’t need to think about it any more. Just follow your routine.
YOGA IS GREAT, BUT BE CAREFUL
By Mark Salamon, September 1, 2017
Many patients tell me that they swear by the benefits of yoga, and for good reason. Studies have shown that yoga can improve flexibility, strength, respiration, energy, vitality, metabolism, weight, cardiovascular health, athletic performance, and injury prevention. (1) And this list is growing as new research comes out. One new study suggested that yoga improves memory and attention, and showed increased cortical thickness in the left prefrontal cortex of people who practice yoga. (2)
However, as with any good physical regimen, there is also a potential for injury. In fact, a new study out of the Center for Injury Sciences at the University of Alabama at Birmingham showed that while two thirds of people reported improvement with yoga, twenty one percent reported that yoga made their muscle or joint pain worse, and almost eleven percent reported new injuries from yoga. (3) This is consistent with what I have seen over the years. I have had many patients come to me with injuries they sustained from doing yoga incorrectly, and while I still promote yoga, I make it a point to educate patients on how to do it properly.The most important thing is to find a good instructor. Most of the injuries I have seen came from people who tried to force themselves into positions that they were not ready for because their instructor was not attentive to differences in age, fitness level, flexibility, or previous injuries. You need to find someone who will take all of these factors into account and pay close attention to all of the people in their class. Look for small classes and get recommendations from others who have taken the class.
Once you have found a good instructor, it is imperative that you talk to them ahead of time about any previous or current injuries you might have. This includes aches and pains that you may think are nothing, but could turn into something serious if your instructor is not aware of them. You should discuss what you should feel while doing yoga. Sharp or severe pain needs to be avoided, and you need to let your instructor know if anything doesn’t feel right during the session. You will probably be sore between sessions if you are a beginner, but you should tell your instructor if you have any symptoms beyond normal soreness.
All of these measures apply to any exercise regimen. Be smart with yoga, and you will reap the benefits.
TO WEAR SHOES OR NOT TO WEAR SHOES
By Mark Salamon, August 1, 2017
Have you seen these things called “toe shoes”? They are shoes that show each individual toe, like a pair of gloves for your feet. They were invented in order to make your feet look even more hideous than they already look in their natural state, and to allow your feet to work in a more natural way. There is also a whole line of “minimalist” shoes out there that do basically the same thing without making you look like a swamp creature. They are all the rage. The kids are all wearing them. It’s tempting to see this as another marketing ploy that will go the way of the rocker-bottom. But there is actually a large body of research that has been examining the effects of this type of shoe, as well as barefoot walking and running, for many years. It is a controversial topic among podiatrists, many of whom still strongly advocate for shoes with tons of support and cushioning, especially where rehabilitating injuries are concerned.
Early studies focused on comparing large populations in countries where supportive shoes are worn routinely with countries where most people wear no shoes. Many of these studies showed surprisingly little difference in overall foot problems, leading many to wonder why we place such a strong emphasis on protective footwear. (1)
More recent studies have looked closely at bio mechanics of walking and running with and without shoes, and have shown remarkable differences that suggest that going without shoes creates a more natural gait pattern which places much less stress on the ankles, knees, hips, and back. (2) (3) This is because with bare feet, we naturally tend to land more on a flat foot, which decreased the impact force in three ways. First, it forces us to fire the small muscles in the feet, which absorb much of the force of impact. Second, it increases the size of the impact area, which mechanically spreads out the force. And third, it allows the knee to be bent more during foot strike, causing it to absorb more shock.
Shoes with tons of lateral support and big, cushiony heels have made us lazy and allowed us to strike the heel first. Even though this feel fine in the short term, it still causes wear and tear in the long term and keeps my clinic full of patients with horrendous heel pain. It also causes the knee to be straighter at impact, which increases the force not only on the knees, but on the hips and back as well. And the small muscles in the feet don’t have to do any work with these shoes, so they get weak and atrophy.
So what’s the solution? In my opinion, it’s not as simple as just recommending that everyone go barefoot or wear minimalist shoes. If you have been wearing supportive shoes your whole life, your feet are not ready for this. They are weak. And your ankles, knees, hips, and back are not used to the flat-foot walking pattern, so an abrupt change could cause real problems. These problems can be magnified with age, because young bodies are more flexible and adaptable to change, as well as an injury or chronic problems such as bunions, hammertoes, or collapsed arches. If you are in this category, supportive shoes may be necessary, and I recommend following your doctor’s advice.
If you are not in this category and are interested in progressing to minimalist shoes or barefoot walking or running, I recommend going very gradually. Start with ten minutes, and add a minute each day. Some soreness is normal, but stop if you have sharp or severe pain. And don’t forget to watch for blisters, especially with running barefoot on sand. In my opinion, if you are a good candidate and acclimate the right way, this more natural way of walking and running can prevent a lot of problems down the line.
By Mark Salamon, July 1, 2017
When my kids were just babies, everyone would say to me, “Hey Mark, how are those little girls? Mark? Are you ok? Mark, wake up, Mark, Mark, (violent shaking) DOES ANYONE KNOW CPR!”
My girls kept me up for fourteen months straight. I shouldn’t say that. I took a twenty minute nap every day at around three in the morning. That’s pretty much all I remember. So I have experienced firsthand the effects of sleep deprivation. (I also took naps sitting at red lights. I wouldn’t recommend this.) It wasn’t a particularly healthy lifestyle. Sleep is essential for repair of all tissues in the body, and many of you already know what it’s like to walk around all day with a body full of unrepaired tissues.
During this time I became a big fan of the power nap. Actually, I had already perfected the technique in college. I didn’t even need to lay down. I could sit in a lecture hall with my head perfectly balanced over my shoulders and fall sound asleep without moving. Other less experienced nappers would jerk themselves awake and fall into the isles, but not me. I can sleep anywhere. If I get tired driving, I pull over and close my eyes for exactly ten minutes (no alarm needed), and wake up completely refreshed. I once took a nap standing up on a bus.
So I was thrilled to see that new research is validating my long held belief in the benefits of this technique. Short bursts of sleep during the day have been shown to clear the brain of adenosine, which is a molecule that is a “byproduct of wakefulness and activity” according to Allen Towfigh, MD, medical director of New York Neurology and Sleep Medicine. High levels of adenosine have been shown to cause fatigue. In fact, about 85% of all mammals sleep for short bursts throughout a 24 hour day, and some sleep experts believe that this may actually be more natural for humans.
Another great trick is to drink coffee just before your power nap. As strange as this sounds, it works because caffeine takes about ten to twenty minutes to kick in, which is just about the time you wake up. And caffeine is also an adenosine blocker, which adds to the effect.
Having said all this, there are still people out there who have real sleep disorders that will not respond to tips from me or anyone else. If you think you are in this category, you should see a doctor to be evaluated. Highly trained physicians often know the instant they walk into the room that a patient has a medical sleep disorder by the way they are still awake after waiting seven hours. It is very important to get treatment if you need it. Sleep is even more important than we previously thought, and it affects literally everything we do, both mentally and physically.
And if you are able to master the power nap, remember, just don’t do it at red lights.
For another great article on power naps, check out Helen Sanders' article in Health Ambition https://www.healthambition.com/benefits-of-power-naps/
By Mark Salamon, June 1, 2017
A good friend of mine emailed me recently with a question about an injury she was almost embarrassed to tell me about. She was in a hotel where the nightstand next to the bed was a little lower than the one she had at home. When she reached over to put her phone down, she felt a little pop in her shoulder with a very minor pain, but ever since then it has gotten tighter and tighter and more and more painful.
She had just had her 50th birthday, so I immediately launched into a lecture on the fact that we’re not 18 years old any more and it might be time to start thinking about cutting back on some of these high risk activities like reaching over to the night stand. I then explained to her that she is not alone. What she has is called adhesive capsulitis, or a “frozen shoulder”, which many people develop even without doing anything crazy like putting your phone down. In fact, most people I see with this condition don’t remember anything happening. The pain and tightness just come out of nowhere.
A frozen shoulder is caused by inflammation of the joint capsule, which is a balloon-like sheath made of thick, tough ligamentous material which surrounds every joint in your body. “Itis” means inflammation, so capsulitis is inflammation of the capsule. Inflammation causes soft tissue to tighten down, resulting in the progressive loss of range of motion. It also causes the layers of tissue that normally glide on each other to stick together, or “adhere”, thus the name “adhesive capsulitis”. Pain occurs for two reasons. First, inflammation causes pain, and second, the tighter the joint gets, the less room there is for the soft tissue to move, which causes more friction and pressure. This in turn causes more inflammation. It is a vicious cycle that will make you realize how debilitating inflammation can be.
So what causes the inflammation in the first place? Inflammation is a built in protective mechanism. It is a biochemical, cellular response to trauma that your body uses to protect itself while an injury is healing. The problem is that it can be triggered by something so minor that you don’t even remember it. Even rolling the wrong way in your sleep can trigger inflammation, and the pain caused by this inflammation can be much worse than the original injury that triggered it.
Acute inflammation is good. It protects injured tissues during healing and subsides within a few days or weeks. Chronic inflammation is bad. It continues long after it has done its job, like a switch that won’t turn off. Over time it can cause the layers that have adhered together to grow into a thick solid mass, making it almost impossible to stretch out, and surgery is often needed to cut the adhesions and separate out the layers. But this does not always work because surgery itself is a trauma that causes inflammation, and this can put you right back where you started.
So it is very important to start treating a frozen shoulder as quickly as possible, and the only way to do this is with stretching. When soft tissue tightens down, the only way to restore its normal flexibility is to stretch it. But you have to do it the right way. If you stretch too aggressively, you can irritate the tissue and cause it to become more inflamed. And if you stretch it in a direction that causes sharp, pinching pain, you are not really stretching, you are just jamming the soft tissue together and irritating it more. Every shoulder is different, so it is important to see a doctor first to rule out a tear or other pathology, and then a physical therapist who can evaluate which motions are tight, determine which stretches are appropriate, and make sure you are feeling the stretches in the right places.
You may run across some articles that say that a frozen shoulder will “thaw out” and get better on its own with no treatment in about 12-18 months. In my opinion, this is old, outdated hogwash. I have talked to many orthopedic surgeons about this, and I have yet to meet one who has seen a frozen shoulder resolve on its own. And even if it were true, who can wait around for 18 months with severe pain?
Don’t wait 18 months. Don’t even wait 18 days. Get this thing checked out now.
DON’T RUN ON A PAINFUL FOOT
By Mark Salamon, May 1, 2017
If you have ever had unexplained pain in the bottom of the foot or heel, listen up. This is called plantar fasciitis, and it is caused by inflammation of the plantar fascia, which is a thick, tough ligament that runs the length of the foot from the ball to the heel. As a student in physical therapy school, I learned how important it is for patients with plantar fasciitis not to run, because the pounding of running can irritate the inflammation that causes the pain. So this is my tip this month: If you have pain in the bottom of the foot or heel, don’t run on it.
If this seems obvious, let me tell you why I feel like I need to mention it. After several years of practicing as a physical therapist, I myself had an onset of unexplained sharp, severe pain in my heel. So naturally I did what any good therapist would do. I went out for a run.
Wait! Before you click back over to facebook, let me explain. I am not an idiot. Well, not about this. I am just like every other health care professional with an interest in research and an obsessive, compulsive urge to prove that everything we ever learned in school was actually wrong. Testing conventional wisdom is what propels science and medicine forward. Many things in medicine are done out of sheer habit, while no one really stops to realize that it was never really proven to work. So I decided to put the no-running rule to the test. For six months. This was precisely the length of time it took me to conclude that running was indeed bad for plantar fasciitis. To be sure, I repeated the experiment a couple of years later, and obtained the same result.
Since this tip is geared towards runners, I don’t feel too embarrassed sharing this story with you, because I know that you runners out there don’t see anything particularly idiotic about what I did. That is because runners are mental. As a runner, I am allowed to say that. And in our defense, plantar fasciitis pain is usually worse when first getting up from sitting or sleeping. Once you are warmed up, running often is not painful at all. So it is logical to think that you are doing no damage. But here is the thing I want to get across. Inflammation is a biochemical process. It is one of the many protective mechanisms your body has to defend itself and heal injuries. Acute inflammation, or the short duration inflammation that occurs after an injury, is good. Chronic inflammation, or the long lasting inflammation that continues for months or years because of repeated trauma, is bad and can lead to permanent damage.
The right type of exercise will promote better healing by increasing blood flow and restoring normal strength, flexibility, and movement patterns. The wrong type of exercise will continue to irritate the inflamed tissues and may turn the good, acute inflammation into the bad, chronic inflammation. And the wrong type of exercise includes anything fast, ballistic, or pounding. This applies to all injuries, not just plantar fasciitis. Slow, controlled movements and gentle stretching are what is needed to increase blood flow and promote healing.
So as painful as it is, put those running shoes away for a while. You may want to bury them in a lock-box in the back yard so you are not tempted. And wait until you have no pain for about a month before easing back into running. Twenty years from now, your feet will thank you.
By Mark Salamon, April 1, 2017
Milk has been a staple of a healthy American diet ever since the 1950’s when impartial government scientists funded by lobbyists from the meat and dairy industries came out with the four food groups. Since then we have worked steadily to earn the coveted title as the country who spends the most on health care and simultaneously has the worst health. But we have not rested on our laurels and become complacent with this reputation. Scientists are still hard at work trying to improve our health even further, and many studies done by scientists not funded by the meat and dairy lobby are showing some startling results.
So my tip this month is that if you want to decrease your chances of osteoporosis, cancer, obesity, heart disease, and high blood pressure, one of the best ways to do this is to cut way back or eliminate dairy products from your diet.
Since everyone associates milk with strong bones, let me tackle this subject first. Many recent (and not so recent) studies have shown conclusively that consumption of dairy products does not decrease your risk for osteoporosis and fractures (1,2), and may even increase that risk because protein from animal products has been shown to increase bone loss (3). I know this flies in the face of what we were all taught from the time we were in grade school, not to mention TV commercials. But the evidence is plain, and is also supported by the fact that people who live in countries with the lowest consumption of dairy have the lowest rates of osteoporosis and fractures. (4)
And what about cancer? We get so bombarded with news reports every day of something else that causes cancer that most Americans tune it out and decide to just eat what they want and enjoy life. And who can blame them? We end up accepting the risk, and our medical system does not help. Our doctors, who are good, caring, smart people, are trained in how to administer medications and perform surgery. And then they are thrown into practices where they are forced to see a new patient every ten minutes. I have had several doctors tell me that if I live long enough I will most likely get prostate cancer, but it is treatable with surgery and medication and I will probably die of old age before the cancer kills me. I have never had a doctor tell me that in countries where they eat almost no dairy, almost no one gets prostate cancer (5). The simple fact is that there is a mountain of evidence that dairy consumption is associated with a significantly higher risk of prostate (6,7), breast (8), ovarian (9), and testicular (10) cancers.
Obesity, heart disease, and high blood pressure are all related, so let me talk about them together. The risks of obesity and heart disease have been shown to correlate with dairy consumption (11,12). Inflammation has been shown to cause high blood pressure (13). And dairy products have been shown to cause inflammation in many people (14). This inflammation stems from the fact that as a species, our bodies were not designed to digest any type of milk after we are weaned, let alone milk from a 2000 pound animal. Dairy contains a sugar called lactose and two proteins called whey and casein (which has a molecular structure very similar to gluten), which are difficult for the human system to digest. Some people get lucky and have no symptoms. Some have vague symptoms that they may not even notice (like low grade high blood pressure). And some have full blown reactions.
There are studies out there that claim that low fat milk actually lowers blood pressure (15). When reading these studies, be alert as to who sponsors them and what websites they are on. The meat and dairy industry has a lot of money, spends a lot of money in Washington, and has a lot to lose.
If you are skeptical of what I am saying, that’s good. You should be skeptical of everything you read, and I encourage you to read more. If you are not sure yet where you stand, my advice to you is this: give it a try. I know this is anecdotal, but I will share with you my experience. I used to consume a ton of dairy, mostly milk and yogurt, every day. So all I did was substitute coconut milk and coconut yogurt. I lost ten pounds without even trying. (I was already thin so the last thing I was trying to do was lose weight.) And for the first time in my life my blood pressure is normal. I’ve had borderline high blood pressure ever since I was a kid, systolic in the 140’s, diastolic in the 90’s. I’ve never taken BP medication, but was always told to keep an eye on it. Now I consistently run systolic right around 120 and diastolic in the 70’s. And cancer, who knows. After fifty years of massive dairy consumption, maybe the damage is done. But maybe not.
by Mark Salamon, March 4, 2017
Ok all you insane workout fanatics and parents of kids who are in sixteen different travel leagues, I’m about to lecture you on one of the most important aspects of training: REST. Professional trainers and athletes know all about this. In fact, any random gym rat could probably educate you properly on the importance of rest, because it is a staple of weight training. But many patients come to me with injuries sustained because they have no concept of the importance of proper rest, so I feel the need to put this out there.
Rest is so important that I once designed an entire training program consisting of only rest days. This didn’t actually work that well, but the point is that rest is much more important than the average person realizes. Training actually breaks down your bodies tissues. This triggers biochemical processes which build those tissues back up later when you are resting. The more aggressive and intense the exercise, the more rest is needed. The most extreme example of this is bodybuilders. They train almost every day, but they work different body parts on different days. High level bodybuilders train each body part for an hour or two in a workout. Imagine working nothing but your chest, for example, for two hours. But they only do each body part once a week. That’s six days of rest for each day of training.
The number of rest days you need depends on several things, including your age, level of fitness, and type of exercise. As a general rule, training that involves many low repetition sets with heavy resistance requires more rest days. As you decrease resistance and increase repetitions, the number of needed rest days decreases. Endurance activities such as running, swimming, or cycling can be considered a low resistance, high repetition exercise and can be done almost every day as long as you build up to this gradually. Stretching can also be done almost every day, but don’t forget to give this a periodic rest as well, because stretching also puts stress on the soft tissues and can cause irritation and inflammation if done too aggressively or too often.
There are many great resources out there to help you design your program, but it can be confusing. No two people are alike, so remember to listen to your body. Pay attention to what causes good soreness or bad pain. If you need help, e-mail me.
And as for kids in sports, I get it. Your kid is talented. They may be able to get a scholarship. If you don’t want to blow their chance, pay attention to what I am about to say. The following applies to all sports, but I’m going to single out baseball pitchers for the sake of example. The last few years have seen the development of strict guidelines on pitch counts for pitchers dependent on age. Yet I still see many patients and their parents ignoring these guidelines and winding up with serious injuries. Kids are pitching in more than one league, so the coaches don’t realize what is going on. And many are pitching year round. If you are the parent of one of these kids, listen carefully. MAJOR LEAGUE PITCHERS DO NOT TOUCH A BASEBALL FOR THREE TO FOUR MONTHS OUT OF EVERY YEAR. If the arm of a full grown athlete at the highest level needs this much rest, what makes you think your child’s growing and developing arm is going to withstand that kind of punishment?
Don’t destroy your child’s chance for success. Whatever the sport, know the guidelines and follow them. Build in an off season and rest days. Cross train with other sports or activities. If you need help or advice, go to the bottom of this page and e-mail me.
by Mark Salamon, February 2, 2017
While the miracle of modern medical technology has put a halt to many horrendous diseases, those afflicted with these diseases still have to live with many painful and uncomfortable side effects and restrictions. Diabetics who use insulin have to deal with needles, pumps, monitors, and dietary limitations. Cancer drugs cause a host of awful side effects including suppressed immunity and damage to other organs. And men dependent on the life saving medication Viagra have to contend with crippling time management issues as they frantically struggle to complete household projects between erections.
Issues arise even with something as basic as an ice pack. Using ice the wrong way can at best eliminate its positive effects, at worst create real damage, including frostbite. This is especially true with modern ice machines that pump a continuous stream of cold water through a sleeve which uses oscillating pressure to compress the affected body part.
Your basic ice pack has been a staple of injury treatment for decades. In 1978 Dr Gabe Mirkin coined the acronym RICE, which stands for Rest, Ice, Compression, Elevation, and this has been standard treatment for the first few days of an acute injury, especially when there is swelling. The duration and frequency of ice application, however, has been all over the place. I have had patients tell me that they were instructed to ice 10 minutes 2-3 times per day, 20 minutes every hour, 30 minutes every 2 hours, and my personal favorite, "just go home and ice the crap out of it".
If this isn't confusing enough, the last couple of years has seen a surge in research suggesting that ice should actually not be used at all. And from the "DON'T EVER BE AFRAID TO ADMIT YOU WERE WRONG" department, a leading researcher in this movement is, you guessed it, Dr Gabe Mirkin, the guy who made up the RICE acronym in the first place.
Making sense of numerous research studies can be tedious. I have reviewed these studies and I am not yet ready to throw away my ice packs. Let me sum up the basics. First, most studies showing that ice did not help, and sometimes even delayed healing, were done on muscular injuries. Second, ice on joint injuries was sometimes shown to be detrimental when the duration was longer than 20 minutes. Third, ice was often shown to be beneficial when used immediately on joint injuries for no longer than 10 minutes at a time.
So I still recommend using ice for joint injuries, especially for swelling, and especially immediately after the injury. This applies to after surgery as well, because surgery is just an organized traumatic injury. Do not ice for more than 10 minutes at a time, and don't repeat this more often than once an hour. Do not use ice on muscular injuries.
And remember, use a barrier such as a towel or pillowcase between the ice and your skin to prevent harmful side effects such as you taking me to court.
by Mark Salamon, January 15, 2017
Have you ever moved the wrong way and strained your back? Me too, And when this happens, I always thought it my duty as a physical therapist to do something, right away, to fix it. I've seen other therapists do it too. We're all alike. We strain our back and then spend the next half hour running around getting others to stretch, crack, traction, push, pull, bend, twist ice, heat, stim, anthing to "fix" it.
I have made this mistake enough times to know that it doesn't work. The more I do, the more it hurts, and the tighter I get. This is because most of the pain from most neck and back injuries does not come from the injury itself, but from your body's response to the injury, namely muscle spasm. This is a protective reflex that is hard wired into your nervous system. Even a minor injury or wrong move can trigger it, and once triggered, it sends signals to the muscles in the area to reflexively contract to protect and prevent further injury. This reflex does not know what the injury is. There might not even be an injury, just a minor wrong move that triggered the reflex. But the more you run around trying to "fix" it, the stronger it will become as it tries harder and harder to protect you.
So instead of fighting it, try the following technique. You may not find this in any book or study. It's just something I've tried with myself and with patients, and it works. It is also safe.
If you move the wrong way and strain your back or neck, just stop. Don't move. If the position you are in is painful, back out of it a little, just enough to get out of the pain. Now just stay there for a minute or two, take deep breaths, and think about your muscles relaxing. Next, move slowly to a standing position and do the same thing. Just stand for a minute or two. Deep breaths. Relax. Now try to walk around slowly, and when this feels fine you can ease back into your regular routine.
Nine times out of ten this will resolve the situation. The concept is simple. Work with your body. Don't fight it.