By Mark Salamon, September 17, 2019
If you have been to a physical therapist lately for a problem involving chronic pain, you may have been exposed to the growing field of pain science. And if you are like a lot of other patients, you may have come out of that visit thinking, “That therapist thinks it’s all in my head.” So let me first put your mind at ease: No, it is not in your head. Your therapist, with the best of intentions, has the same problem a lot of therapists are having: they are not articulating, explaining, and utilizing pain science the proper way.
Let me first briefly explain what pain science is. Over the last several years, researchers have made great strides in understanding that pain is far more complex than previously thought. The old model of pain was simple: Something physical irritated a nerve, which sent a pain signal to the brain. We now know that sensations of pain in the brain can be caused by many other things, including chemical or hormonal imbalances, previous experiences, fear, worry, sleep deprivation, lack of activity or movement, and many others. This does not mean the pain is “in your head.” These things cause actual, physical pain that is not imagined.
Studies have shown that patients who are given pain science education have better outcomes with regard to decreasing their pain. This education can range from an informal ten minute explanation to a full blown power point presentation. The mistake some therapists make is they interpret these findings to mean that explaining pain science to patients will decrease their pain. This is not true, and therapists who believe this often come across as thinking that their patient’s pain is all in their head.
In my experience, the most significant benefit of pain science education is helping patients with chronic pain understand that gentle activity and movement will not make their pain worse, and if done properly will actually make their pain better. Lack of activity and movement actually causes pain, even with no injury or pathology. If you don’t believe me, try wearing a sling for a couple of days. I’ll bet money that your shoulder and elbow will get so sore that you will rip that sling off before the end of the first day. That is real pain. It is not in your head, and people who are afraid to move are doing this very thing to their bodies.
Pain science education must be used properly in appropriate situations. If you just had knee surgery yesterday, you will have pain, and no amount of pain science education will change that. But as the days and weeks progress, if you are afraid to gradually and gently move your knee the proper way as instructed by your therapist, your pain will persist long after it should have subsided, and pain science education will be of great benefit.
If you want to learn more about pain science, there are many great online resources, like painscience.com, and many physical therapists including Jarod Hall, Greg Lehman, and Adam Meakins have done extensive work on pain science and are worth checking out.
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TO LOSE WEIGHT AND BE HEALTHY, YOU NEED MORE THAN EXERCISE
By Mark Salamon, August 1, 2019
As a physical therapist, I spend most of my day prescribing exercises to deal with injuries or promote good health. So when people ask me which is more important, diet or exercise, they are always surprised when I say diet. Now don’t get me wrong, exercise is important, but not nearly as important as diet when it comes to good health. I have treated exercise fanatics who eat garbage, and are riddled with health problems like diabetes, high blood pressure, and heart disease.
Many people still subscribe to the “I eat whatever I want because I work out so hard I burn it off” mantra. This drives me crazy, and a new study published in The American Journal of Clinical Nutrition has boosted my arsenal for convincing people to abandon this misguided belief. Results of this study showed that most people who started an exercise program did not lose nearly as much weight as expected, and many lost no weight or actually gained weight. (1)
The study identified several factors that could be responsible for the disappointing results, and most had to do with compensatory behaviors such as eating more or moving less during non-exercise times. But this doesn’t even address long term consequences, which are much more important. Young exercise enthusiasts in particular tend to think they can eat whatever they want, because they often feel great, look great, and have perfect physical exams and blood work. The problem is, a poor diet causes slow, virtually undetectable damage which later in life causes much higher risks of serious health problems.
Again, exercise is important. But if you had to choose one or the other, think of it this way: If you have a great diet and don’t exercise, you will likely be very healthy. But if you exercise and eat junk, you are setting yourself up for serious health problems.
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WHEN TO TAKE ANTI-INFLAMMATORY MEDICATION - MY THEORY
By Mark Salamon, July 1, 2019
A growing body of evidence is showing that daily, long term use of ibuprofen or other anti-inflammatory drugs can increase the risk for serious stomach, liver, kidney, and heart problems, weaken tendons, and delay healing. Long term users can also develop a resistance which causes diminished effect or increased pain, and stopping abruptly can cause severe rebound pain. (1,2,3,4,5,6,7,8)
Occasional short term use, however, is safe, but there is no research on the best way to use anti-inflammatories in this manner. Most people assume that if you strain your back or wake up with a stiff neck or over-do it trying to play soccer with your kids, you should just pop a couple pills and get rid of the pain. In my opinion, there is a better way to treat this short term pain for the following reasons.
Inflammation is a series of biochemical reactions that initiate tissue repair, and is a necessary part of healing. Because it can cause the injured body part to become hot, red, painful, or swollen, people assume that it is bad. We don’t like to be uncomfortable. But without this short term process, healing will not occur properly.
Short term, or acute inflammation should subside in a few days. Harmful effects of inflammation only occur when this does not happen. Sometimes inflammation persists for weeks, months, or even years, like a switch that gets stuck in the “on” position. This long term, or chronic inflammation can cause severe problems including permanent tissue damage.
So back to the use of anti-inflammatory medications: If you take a pill when you first have pain, you will knock down the acute inflammation before it has done its job. This may be one reason why pain often returns when the medication “wears off,” and people end up taking medication for several days. My theory is the following: Let the inflammation do its job for a day or two. You may be sore and swollen, but tough it out. Remember, acute inflammation is necessary for healing.
If you still have pain after about two days, this may be a sign that the inflammation is not subsiding the way it should, and is turning into chronic inflammation. This is the time to take medication.
I have not found any research to support or refute this method, but I have tried it on myself several times with excellent results. In fact, many times I end up not taking anything because the pain subsides on its own after two days. This indicates to me that the acute inflammation has done its job, and is subsiding on its own as it should. If I still have pain after two days, medication works much better than when I used to take it immediately. This indicates to me that allowing the acute inflammation to do its thing improved healing quality.
Again, I must emphasize that this is only my theory, and has not yet been backed up by research. But I think it is worth a serious look.
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HOW DO YOU GET YOUR PROTEIN?
By Mark Salamon, June 1, 2019
My three daughters are vegan, which means they have the superhuman discipline and self control needed to prevent them from strangling the next person who says, “so where do you get your protein?” If you are in the habit of asking this question, please be advised that this is an extremely dangerous activity that at some point, statistically speaking, is all but guaranteed to get you dope-slapped into next week. On the other hand, if you are someone who routinely gets asked this question, I urge you to contain your violent impulses long enough to read this article and learn how we can educate all members of our society in a peaceful, civilized manner.
I am a plant-based eater myself. “Plant-based” means that most of what I eat comes from plants. I prefer this term because it sounds better than what I used to call myself: a vegan who cheats a lot. But the point is, I too have to deal with questions from people who never seemed to notice that horses and elephants have no trouble getting enough protein without eating cheeseburgers. So here is what I say to those who honestly don’t know and want to learn: plant-based foods are packed with protein, and you don’t have to eat enormous quantities to get enough. Horses and elephants eat enormous quantities because they are slightly larger than us. The recommended amount of protein is about .36 grams per pound of bodyweight, and you can easily get this much from normal amounts of fruits, vegetables, nuts, seeds, beans, rice, oats, and grains. For example, consider the following typical day for a vegan:
Breakfast: oatmeal (5g) mixed with chia seeds (5g), fruit (3g)
Snack: peanuts (10g)
Lunch: quinoa (8g) mixed with broccoli (5g) and corn (5g)
Snack: fruit (3g) mixed with sunflower seeds (10g)
Dinner: rice (5g) mixed with beans (15g), a potato (5g), and peas (8g)
This is not an enormous amount of food, but it contains 87 grams of protein, which is enough for a 240 pound man. Now the nice thing about being plant-based is that if you want to be healthy and keep your weight down, and you also want to consume an enormous amount of food, you can. Eat as much as you want. Imagine it, no counting calories or limiting portion sizes.
So now that we have that cleared up, I want to warn you about another dangerous activity you should avoid: telling vegans that you admire them for their willpower. Take it from my daughters, it takes no willpower at all. Once your body becomes accustomed to the foods it was meant to live on, you won’t even think about cheeseburgers.
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TRAINING IS SPECIFIC
By Mark Salamon, May 1, 2019
A friend of mine gets up at 5:00 am every day and runs on his treadmill for 30 minutes. He’s been doing this for years. “It’s like brushing my teeth,” he says. After trying many different exercise routines - biking, elliptical training, swimming, weightlifting - he settled on running because it was the hardest, and he felt that it gave him the best workout.
A few months ago my friend’s treadmill broke down, and he was told it would take several weeks for the replacement parts to be delivered. So during this time he switched to his elliptical trainer. After the first day of this new workout, he told me that it was really hard, harder than running, and that he was surprised because he remembered the elliptical trainer seeming fairly easy when he tried it years ago.
He continued his daily 30 minutes on the elliptical trainer for what turned out to be a month before his treadmill was diagnosed as irreparable and replaced with a new model. By this time he was planning on sticking with the elliptical trainer, as it still felt like a harder workout than running. But for a change of pace, and to try out the new treadmill, he got up at 5:00 am and ran. To his surprise, the run felt much harder than the elliptical trainer.
He asked me what was going on. Why did running feel harder, then the elliptical feel harder, and then running feel harder again? The answer boils down to a standard principle of exercise known as specificity. Simply put, your body gets good at the specific thing you train it for. Running gets you in shape for running, not elliptical training. And doing the elliptical trainer gets you in shape for the elliptical trainer, not running.
Now, overall fitness does have some carryover. If you train on the elliptical machine every day, running will be easier than if you hadn’t trained at all. But running will be much easier if you run every day.
Even high level athletes experience this phenomenon. High school and college athletes who play several sports all tell the same story. I was just talking to a young woman who plays field hockey in the fall and basketball in the winter. You would think that field hockey, which involves short bursts of fast running, as well as cutting back and forth, would prepare her for basketball. But every year, she tells me, she is extremely sore during that first week of basketball practice. Being in field hockey shape is completely different than being in basketball shape. It really is that specific.
For the average person just trying to be healthy and stay in shape, the lesson here is the importance of cross training. That is, mix up your workouts. Doing different things on different days will result in better overall fitness and prepare you for many different activities. If you are a creature of habit and thrive on the same routine every day, consider changing your routine every few weeks or months. Not only will this improve your overall fitness, but it will decrease repetitive stress on specific structures and, thus, decrease your chance of injury.
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DIFFERENT TYPES OF STRETCHING FOR DIFFERENT OCCASIONS
By Mark Salamon, April 1, 2019
If you are like millions of Americans who believe that stretching is good for you, you are right. Soft tissues become tighter as you age, and this tightness can cause many aches and pains that can be eliminated by proper stretching. In addition to lengthening soft tissue, stretching also induces stem cells to differentiate into soft tissue components such as collagen, which basically means that it makes your body produce more of the elastic materials that make up your soft tissues. (1) Stretching also increases blood flow and angiogenesis (the formation of new blood vessels), which is great for all tissues in your body, especially those that are healing. (2)
Even if you are a stretching enthusiast, you may not realize how many ways there are to stretch. Of all the types of stretching, I have narrowed it down to three that I recommend for most people for different situations.
The first is static stretching. With this technique, a joint is pushed to its end range and held there for a sustained period without bouncing. This hold is usually ten to twenty seconds, and this is repeated about four to five times with a second or two of rest in between. Static stretching is the most effective way to lengthen soft tissue, so it is the method of choice to restore normal range of motion to tight structures. Static stretching has been shown to actually increase the number of sarcomeres - the microscopic units of muscle tissue - if done consistently over long periods of time. (3)
You need to be careful with static stretching, because if done incorrectly or at the wrong times, it can actually cause injury or worsen athletic performance. (4) Static stretching should not cause sharp pain in a joint, but rather a good, stretch-type pain in a muscle. It should not be performed first thing in the morning or right before activity, especially fast, ballistic activity such as sprinting. The best time to perform static stretching is at the end of a workout when you are fully warmed up.
The second type of stretching that I employ is called dynamic stretching, which uses gentle swinging motions that take a joint to its limit at each end of the swing. Start with short swings, build up slowly, and don’t go past the point of comfort. If done too fast or aggressively, dynamic stretching can cause injury, but if done correctly it is safer than static stretching. I recommend dynamic stretching as a warm up before a workout or athletic activity.
The third type of stretching I utilize is active stretching. When you get out of bed and stretch your arms over your head, you perform an active stretch. This type of stretch moves a joint to the end range of motion using the joint’s own muscle contraction, as opposed to you or someone else applying over-pressure during a static stretch. An active stretch is one of the best ways to treat a fresh injury because it generates less force than a static stretch, and it is slower and more controlled than a dynamic stretch.
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By Mark Salamon, March 2, 2019
I ran track and cross-country in high school, and I’ll never forget one particular line that my coach would repeatedly say: “If you want to run faster, you have to run fast.” This sentence justified our workouts, which almost always consisted of running repeated distances that were much shorter and faster than the race we were training for. This was known, back in the early 80’s, as “interval training.” We almost never ran long, slow distances, even when training for a three-mile race.
As I grew into adulthood, I stopped competing, but continued to love working out. Intense interval workouts gave way to long runs or bike rides, and I would spend hours in the gym lifting heavy weights with long breaks between sets.
When I got married, bought a house, and had kids, my days of long workouts were over. I didn’t want to completely let myself go, so drawing on my high school training experience, I devised short, interval-type workouts that I could complete in ten or fifteen minutes. I applied this scheme to running, biking, and weightlifting, and discovered that these workouts kept me in as good, if not better shape than long hours in the gym. I knew I was onto something, and as a physical therapist, I figured that some day I would find a way to go public with my unique training regimen.
Well, I missed the boat on that one, because now those types of workouts are all the rage. And for good reason. Studies show that short bursts of high-intensity exercise are as effective, and in some cases more effective, than long, slow activity for improving several measures of fitness. (1, 2, 3, 4, 5)
This type of training even has a name: HIIT, or “High Intensity Interval Training.” A HIIT workout can be created for just about any activity, like running, biking, weightlifting, or bodyweight exercises such as squats and push ups. I especially like HIIT workouts because they prove that us middle-aged dorks weren’t total morons back in the 80’s.
HIIT workouts are not for everyone, so if you have any medical issues, check with your doctor to make sure you are safe. If you are not in great shape and haven’t exercised in some time, start slow and progress gradually. YouTube is full of great HIIT workouts for people at all levels. If you are not sure where to start, I recommend Fitness Blender for great, free workouts that range from five minutes to an hour and a half.
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By Mark Salamon, February 1, 2019
So I’m making small talk with a patient the other day while stretching his hamstrings, and he starts telling me about these dietary supplements that he sells. Apparently, each one of these pills contains the equivalent of eight servings of fruits and vegetables. Within minutes he was headlong into a full blown sales pitch about the incredible health benefits of these pills. I listened politely until I could tell he was wrapping it up. I have to say, his speech was quite polished, which made me all the more eager to see his reaction to my response. I could tell by his confident tone that he was not prepared for what I was about to say: “I agree one-hundred percent, almost all I eat are fruits and vegetables.”
“Really?” he said. And then he was silent. It was as if the thought had never occurred to him that some people would actually try to get the health benefits of fruits and vegetables by EATING FRUITS AND VEGETABLES. I am not kidding when I say that was literally the end of the conversation. He was dumbfounded. Hating awkward silence, I expounded on what he had already said about the benefits of fruits and vegetables, and told him more about the foods that I eat. He then proceeded to describe his diet, which consisted of basically everything except fruits and vegetables.
Unfortunately, this is the story of the typical American who honestly and sincerely wants to be more healthy. I don’t blame them, because the bulk of information that is readily available to the public comes from the mainstream media. And the mainstream media gets most of its funding from large companies that that make things like dietary supplements.
So let me make this tip short and simple. My pill-selling patient was right about one thing: The health benefits of fruits and vegetables are indeed huge. However, these health benefits are greatly diminished when put into pill-form. Absorption and beneficial interactions are orders of magnitude higher with real food, and unless you have a medical condition that requires supplementation, you can get all the nutrients you need from real food. In fact in some cases, supplements can do more harm than good. (1, 2, 3, 4, 5, 6)
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MAKING SENSE OF RESEARCH
By Mark Salamon, January 1, 2019
Tell me if this sounds familiar. New research shows that a particular food drastically reduces your risk of heart disease and stroke. You buy enough of this food to feed the Green Bay Packers for a year. Six months later a breaking news report says that this same food has now been shown to cause your body to produce enough cholesterol to plug a water main break.
This scenario takes place every day in America. So when patients tell me they are fed up and are going back to their Fritos and clam dip diet, I honestly can’t say that I blame them.
Here’s the problem: the FCC has spent too much time regulating which bad words the news media isn’t allowed to say, and not enough time regulating things that the news media should never, ever, be allowed to talk about, like research.
Research is vastly more complicated than the news media would have you believe. For any given topic, there could be hundreds, or even thousands of studies, some of which contradict each other. One particular type of study called a meta-analysis statistically evaluates hundreds of other individual studies to determine the overall direction of the findings. If you listen to serious scientists debate research, they not only talk about many individual studies, but many different meta-analyses. This painstaking process is done in an effort to ascertain what is suggested by the entirety of the research. In this world of real science, the results of any one single study are nothing more than one small data point that may or may not be valid.
The news media, however, loves single studies, because their target audience has the attention span of goldfish. The twenty-four-hour news cycle survives on sound bites. Things that sound good, valid or not, improve ratings. And ironically, the constant shift in what is good for you and what is bad for you improves ratings as well. It infuriates the public, and this keeps them tuning in. It’s like watching a bad soap opera.
So just realize that in today’s world, news is entertainment. The upside is, real information is not that much harder to find. Leading nutrition researchers like Joel Kahn, Chris Kresser, Joel Fuhrman, and many others can be followed online, and their discussions and debates can be heard on podcasts and Youtube. It takes a little more time and effort, but it is well worth it.
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DON’T COMPARE YOURSELF TO OTHERS
By Mark Salamon, December 1, 2018
I work in an open physical therapy clinic where patients are in close proximity to each other during treatment. One of the best things about this type of setting is that many patients get to know each other and give each other support and encouragement through the rehab process. One downside, however, is that patients tend to compare themselves to each other.
Picture this: patient number one had a total knee replacement a month ago. She is lying on the table as I help her bend her knee as far as she can. I take a measurement. Ninety degrees. “That’s great!” I say. Patient is pleased.
Patient number two is lying on the table next to patient number one. Patient number two had a total knee replacement a week ago. I help her bend her knee as far as she can and take a measurement. One-hundred-and-ten degrees. “Fantastic!” I say. Patient number two is pleased, but patient number one suddenly feels like the biggest loser in the history of the universe, and I spend the next hour trying to convince her that she is, in fact, doing very well.
So here’s the deal. No two surgeries are alike. No two people are alike. No two knees are alike. Everyone improves at their own pace, and if you try to compare yourself to your neighbor who had the same surgery and was back to playing in the NFL in three weeks, you are going to drive yourself crazy.
I have also treated many patients who have surgery on their knee, and then years later have the exact same surgery on their other knee. (or shoulder, or hip, or whatever) The recovery for these two surgeries is almost never the same. One is always worse than the other, and often the one “the doctor said was worse” turns out to be the one that has the easier course of rehab. It is completely unpredictable. So the moral of the story is that you can’t even compare yourself to yourself, so you certainly should not compare yourself to someone else.
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DON’T SIT. DON’T STAND. DON’T WALK. THEN WHAT, FLOAT?
By Mark Salamon, November 1, 2018
Anyone who has picked up a newspaper in the last couple of years has read about the dangers of prolonged sitting. The average office worker sits for fifteen hours per day (1), and studies have shown that this correlates with increased risk of diabetes, heart disease, obesity, and early death. (2, 3, 4, 5) Even more alarming, studies have also shown that exercise does not offset these risks (6).
These findings led to the development of standing desks. It seems intuitively obvious that standing all day would be healthier than sitting all day, but further studies uncovered some unexpected problems. Standing all day, it turns out, doubles heart disease risk, increases the risk of chronic back pain and other musculoskeletal disorders, and increases oxidative stress, pressure in the veins, and blood pooling in the legs. (7, 8, 9) Furthermore, research has also shown that while sitting burns roughly eighty calories per hour, standing only burns eighty-eight calories per hour, hardly a significant improvement. (10)
Walking, however, burns approximately 210 calories per hour, which led to the development of walking desks. These are desks mounted on treadmills that allow workers to walk at a slow, steady pace while performing their duties. Unfortunately, there are downsides to this strategy as well. One study showed that those who walked on a level setting at 1.5 miles per hour showed decreased typing speed and accuracy, and lower performance on cognitive tests of working memory, delayed recall, and concentration. (11)
All of this research has led the typical office worker to ask, “so what are we supposed to do?” To date, the best answer is a combination of sitting, standing, and walking. Most health experts had been recommending that people stand for about fifteen minutes every hour, but recent research by Jack Callaghan, professor in the department of kinesiology at the University of Waterloo, shows that the optimal time for standing is thirty to forty-five minutes every hour. (12) Adjustable height desks can run from several hundred to over a thousand dollars (13). Many employers may be hesitant or simply unable to pay, so it might be up to the employee
to negotiate or come up with creative ways to get out of the chair. This could involve things as simple and inexpensive as putting the laptop up on some boxes, or figuring out what aspects of the job could be performed while standing or walking around the office.
Variety is the key. Mix things up as much as possible. This will improve not only physical health, but mental and emotional health as well.
NO AMOUNT OF EXERCISE IS TOO LITTLE
By Mark Salamon, October 1, 2018
How long do I need to exercise every day? Which is better, the bike or the stairmaster? Should I use machines or free weights? Patients ask me these types of questions every day because making sense of the latest research and recommendations is about as easy as figuring out their insurance bills.
There is no shortage of articles that boldly state specifics. If you enjoy variation, you’re in luck, because these specifics change constantly. With this in mind, one of the best ways to design an exercise program is to employ the following strategy. First, pick the machine that you enjoy working out on the most. Second, decide how much time you want to spend exercising every week. Third, wait for articles to come out stating that your particular machine and time frame are optimal for good health. This should take about a week.
Like many physical therapists, I experiment with my own body to gain insight which I then pass on to my patients. As my career unfolded over the years, I progressively worked more hours, had more kids, fixed more things around my house, and consequently had less time to exercise. So I adapted by designing workouts that took less time, and found that it is entirely possible to get a good hard, effective, productive, beneficial workout in ten minutes, five minutes, two minutes. Fill in the number. How much time to you have?
Patients have told me that they have given up trying because they just can’t spare the time recommended by articles they read. Or they just can’t afford the particular machines that are supposed to burn the most calories. Please don’t be one of these people. Many well known and respected researchers are now promoting what I have been privately doing for many years. No amount of exercise is too little. Taking the stairs instead of the elevator, even if it is only once a day, DOES have a beneficial effect. And this machine is not better than that machine. The machine does not do anything. What you do on the machine is what counts.
TO BRACE OR NOT TO BRACE
By Mark Salamon, September 1, 2018
No matter the injury, one of the most common questions I get from new patients is, “should I wear some sort of brace for this?” Very often the answer is no, for the simple reason that any type of bracing actually makes you weaker, because the brace is doing some of the work that your muscles should be doing.
Having said that, there are situations that do require bracing. If there is a tear in a ligament, this will often require bracing. Ligaments connect bone to bone, and a torn ligament can allow a joint to move in a direction that it is not supposed to move. This can cause the joint to become unstable, meaning that it could buckle under your body weight, so bracing is needed to hold the joint in place during the healing process. This also holds true for the first few weeks after a surgical ligament reconstruction, as the repaired ligament needs time to heal before it can withstand any load without tearing again.
A torn muscle or tendon may also require bracing to prevent you from contracting the muscle and worsening the tear. Again, this also applies to post-operative repairs, such as rotator cuff repairs in the shoulder.
Broken bones often require bracing or casting to prevent movement between the ends of the bones that are healing together. If there is continued movement between these bones over several weeks, the ends of the bones at the fracture site will calcify to the point where they will never grow back together. This is called a malunion.
But in the absence of a break or at tear, most injuries will be made worse by bracing, as it will make it more difficult to restore full strength to the injured area. Compression sleeves can be beneficial if there is swelling, but even these can cause weakness if worn for too long, so they should be discontinued when the swelling has subsided.
Protective braces are sometimes used for uninjured people who perform activities with a high risk of injury. Football players often wear knee braces only during games or practice, and this will not affect strength. And back braces are often recommended for people who do a lot of heavy lifting, but these should not be worn all day. Rather, they should be pulled tight just before the lifting occurs, and then loosened after the lifting is complete.
The bottom line is that you need to find out if you have a break or a tear in order to make a decision about bracing. So make sure to have your injury evaluated by a physician.
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.
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.
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.
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.
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.
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.
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.