Welcome!

Welcome to Athletic Medicine! This blog is an expression of my passion for sports medicine, performance enhancement, fitness, nutrition, and general health. My intention is to comment and share relevant research, interesting news stories, and create discussion for hot topics. Please click the “follow” button to receive email notifications of new blog postings.  Again this is intended to spark debate and discussion – so please share thoughts on any posts.  You can read my bio here.  Also, please follow me on twitter.

Cheers -

Josh

ACL Injury: New Information on Prevention, Rehabilitation, and Consequences

I have written about knee injuries so much. Every day we are bombarded with research that quite frankly, it gets boring. The problem is with approximately a quarter-million ACL injuries per year, it is safe to say the injury is rampant. The devastating nature and commonality of the injury has provided loads of information on prevention, rehabilitation and mechanisms of injury. I am not going to regurgitate them all, but do want to share some recently published articles that sports medicine experts should read.

Article 1: Negahban, Et al. A systematic review of postural control during single-leg stance in patients with untreated anterior cruciate ligament injury. Knee Surgery Sports Traumatology and Arthroscopy, May, 2013.

I love systematic lit reviews and this SLR aimed to determine postural control on those with ACL injuries. We have many internal systems and senses that help us balance.  Beyond the use of our eyes and ears to sense balance, tiny mechanoreceptors and proprioceptors exist in our tissue that sense abnormal movement. This study found that when the eyes are closed individuals with ACL injuries had increased postural sway and loss of balance. This indicates that the injury and inflammation following injury inhibits our body’s internal mechanism to sense balance. When rehabilitating, be sure to emphasize proprioception exercises.

Article 2: Thomas, Abbey, et al.  Lower Extremity Muscle Strength After Anterior Cruciate Ligament Injury and Reconstruction. Journal of Athletic Training published online first, 2013.

Despite advances in rehabilitation and the numerous studies published on ACL rehabilitation protocols, we appear to be failing. This study shows that at 6 months Status Post ACL reconstruction that global weakness still exists. When comparing strength output from injured vs. uninjured legs it appears the knee-extensors (quads) and knee flexors (hamstrings) are weaker at 6 months when compared to the contralateral side. Conversely hip and ankle strength was not significantly different at 6 months. The timeline to return a player back to competition and activity is 6 months following activity and/or 95% strength of the uninjured side. This study indicates 6 months might be too early. Also, we may need to adjust our strengthening protocols to further stress knee flexion / extension strength.

Article 3 – Bell, DR, Clark, MA, Padua, DA, et al., Two- and 3-Dimensional Knee Valgus Are Reduced After an Exercise Intervention in Young Adults With Demonstrable Valgus During Squatting. Journal of Athletic Training published online first, 2013.

Darin Padua and the UNC Department of Exercise and Sport Science has done a lot of work on knee displacement and correlating the findings with ankle hypomobility and hip underactivity. This particular model used the NASM Corrective Exercise Model as the intervention procedure. This method systematically turns off hyperactive tissue and activates hypotonic tissues. The data revealed that following intervention of the ankle and hip medial knee displacement was significantly reduced.  This information is important as several studies have shown medial knee displacement to be a primary cause of ACL injuries and chronic knee pain.

Article 4: Ericksen, et, al. Different Modes of Feedback and Peak Vertical Ground Reaction Force During Jump Landing: A Systematic Review. Journal of Athletic Training published online first, 2013.

The inability of the body to absorb and control joint movement during high levels of ground reaction forces has been shown to increase risk of ACL injury as well as other chronic knee conditions.  This study evaluated the effect of expert provided and self-analysis feedback reduced peak ground reaction forces. This is not a paramount study but does shows the effectiveness of verbal queuing and observation to correct suboptimal neuromuscular control, specifically during landing and absorption of ground reaction forces through the kinetic chain. Rehab practitioners should incorporate feedback to teach clients appropriate muscle control during ACL rehabilitation.

I would like to say thank you to Darin Padua, PhD, ATC for keeping me abreast with current data. Darin is a leader in sports medicine research and specifically has many published papers on ACL injuries. Darin manages his blog site and also shares info on his twitter account. If you are a health and wellness professional seeking important information rehabilitation and prevention of injury, I recommend you give Darin a follow.

Cheers!

Post-exercise Nutritional Tips for Improving Performance and Recovery

My former co-worker giving me a stretch during the Spartan race after cramps set in.

A couple of weeks ago, I participated in a 5k and a 10k challenge that was scheduled 12 hours apart. Fitness enthusiasts would consider a back to back 5k / 10k as just another training session. I, on the other hand, am quite the opposite. I have developed a hate-hate relationship with aerobic exercise –specifically, running. I like speed, agility, quickness, strength, and power – arrg arrg arrg! I am five foot nothin’ and a hundred somethin’ (emphasis on the nothin’ and somethin’).  I would rather pluck my eyelashes than run. But, I do love the exercise science.

You’d think I’d use my knowledge for exercise science as a useful tool. Unfortunately, my continued pursuit of knowledge does not translate to practical utility. What follows is what I should have done to enhance recovery and optimize performance during this short 12 hour recovery period between races. Since, I won’t listen to myself, maybe you will!

First, we must understand the physiology of producing energy, fatigue and recovery. I do not want to turn this in to an advanced exercise physiology session on metabolic pathways but this general background is helpful. When we exercise energy (ATP) is needed.  This energy is created by our body using three systems:  ATP-PCr system, the glycolytic system and the oxidative system. Each energy system has its own method of generating energy. Likewise, each energy system becomes fatigued after an imbalance occurs in its system.

In the ATP-PCr system our body uses stored Phosophocreatine and through a series of reactions quickly generates ATP. Unfortunately, this system gets depleted of stores rather quickly. This is why you can only perform and all out sprint for 10 – 20 seconds. After a 2 minute rest period the ATP resynthesizes giving you the ability to perform an all-out sprint again. If we going longer than 20 seconds our body must enter the glycolytic system. Here we begin to use glycogen to make energy. When glycogen is broken down without oxygen present, our cells becomes acidic (commonly known as lactic acid buildup or lactate threshold). This acidity inhibits enzyme activity. Since enzymes are the catalysts for almost all body functions, we fatigue when they stop working.

If intensity is low enough in the glycolytic system, our body has time to use oxygen to breakdown glycogen and prevent lactic acid build-up. This is the oxidative system. Using oxygen to breakdown glycogen is our long-term energy system, which we use to perform tasks like distance running. Carbohydrate is stored in our body as glycogen in muscle and liver. This is our preferred and primary energy source. However, when we exercise we deplete glycogen stores and sometimes have to call on fat to make energy. When we reach this phase our body will fatigue. So, in review, during high-intensity exercise we fatigue because we deplete ATP and Phosphocreatine stores. During moderate activity we fatigue due to lactate build-up. During long and steady state exercise we fatigue when glycogen stores become depleted.

To combat this fatigue we must train our body to adapt to these physiological changes, or provide opportunity for our body to recover through rest. You can also practice good post-exercise refueling habits. By eating and drinking macronutrients (carbohydrate, fat and protein) we replace what we just used. So, what do we eat and when do we eat to replenish?

A Study published by Howarth, et al., in 2009 found that ingesting a carbohydrate and protein mixture at a 4:1 ration provided the best benefits when compared to carbohydrates alone. Similarly, Koopman, et al., in 2005 found a 3:2 ration of carbohydrate to protein ingested post exercise was better than carbohydrate alone. The Koopman study also investigated the benefit of leucine – an essential amino acid found in soy, beef and salmon, known to facilitate muscle regeneration – and demonstrated an added benefit of this supplement. Even though some current data is contradictory most studies show that the amount of glycogen formed is significantly greater in athletes consuming the mixture of Carbohydrate and Protein.

Timing also plays an important role. You may have heard of nutrient timing – it’s getting a lot of attention lately. In order to compensate for protein loss during exercise, the timing of post-exercise protein supplementation is important. The efficiency of protein synthesis is improved by ingesting rapidly after exercise.  Another challenge is the refueling with carbohydrates. Bottom line, the sooner carbohydrate is consumed post-exercise; the greater the amount of muscle glycogen is resynthesized. When time is short between fuel-demanding events, it makes sense to start refueling as soon as possible.

Keep it simple, post-exercise meals should be built on a foundation of carbohydrate-rich foods plus a smaller amount of protein. Greek yogurt or cottage cheese with fruit or bananas with peanut butter are both good options. If you are a stickler for protein powder, switch it up – make yourself a fruit smoothie and add a scoop of protein.

My times for the 5k and 10k were 29:37 and 63:26 respectively; certainly not awesome.  Maybe if I’d apply what I know, I would have done better. Maybe if I replenished with a healthy carbohydrate protein drink instead of beer and pizza, I would have done better on day 2. If I’d just listen to my brain and not my fat cells I might have finished under 60 minutes. If I’d listen to my brain, not watch the ESPN, I could improve. If I chose to get up rather than drool on my pillow, I might approach 45 minutes. Someday I will get the hint and practice what I preach. Maybe I need the late Chris Farley’s famous character, Matt Foley, as my personal motivational speaker.

A Blog Inspired By and Dedicated to Runners

I have been looking for something to blog. No idea surfaced that said, “Yes, that is a great blog idea.” That was until yesterday’s tragic Boston Marathon bombing. Runners are a rare breed. You cannot keep them down. A runner’s passion for sport, resilience to challenge, and unique characteristic to rise above is unparalleled by any other athlete. I am not a runner. In fact I am the antithesis of a runner. I go in to anaphylactic shock just hearing the word aerobic exercise, but have many friends who are passionate runners. I dedicate this blog to my running friends, competitors of the Boston Marathon, the friends and family of those impacted by yesterday’s events, and runners everywhere from the competitive to non-competitive. I will keep it true to my blog site and remain sports medicine focused. I hope you find the information useful.

Running is one of the most popular recreational sports in the US. Race events can be found in almost every town. My town – Champaign, IL – has 2 events in the next 4 weeks. Some estimates say 20% of the population is runners and 10% of these people participate in race events. The benefits of exercise are well documented. Running has shown to build confidence and character, reduce stress and improve mood. However, the due to their very nature – the unwillingness stop – running does bring about an increased incidence of musculoskeletal injury.

You don’t need to be an astrophysicist to know running injury is secondary to cumulative overload. Running injuries are multifactorial; neuromuscular imbalance, poor arthrokinematics and other things such as age, nutritional status and environment are to blame. From a biomechanical point of view frontal plane knee adduction moments play a significant role in lower extremity injury. Q-angle – a measure of knee alignment – can indicate risk for running injury. An increased Q-angle can be a result of many neuromusculoskeletal inefficiencies from poor muscular hip control to limited ankle dorsiflexion and excessive forefoot pronation.

Running brings about many injuries, but the most common are Patellofemoral Syndrome, Iliotibial Band Syndrome, Medial Tibial Stress Syndrome / Tibial Stress Fracture, Achilles Tendinitis, Plantar Fasciitis, and Sacroiliac Joint Pain. What is interesting is that all of these injuries can be caused by biomechanical breakdown and neuromusculoskeletal inefficiency. The good is the dysfunctional patterns are identifiable, preventable and correctable. Below is a sample 15 minute injury prevention program from a blog I wrote in Sept 2012. Yes, 15 minutes is all you need to prevent many running injuries.

Step 1: Decrease neurological drive to hypertonic tissue – 3 minutes

• Self-Myofascial Release (foam roll) or Manual Trigger Point Therapy
  • Gastrocnemius/Soleus – 60 seconds
  • Adductors – 60 sec
  • TFL/IT-band – 60 sec

Step 2: Lengthen hypertonic muscle or joint tissue – 3 minutes

• Static stretch or joint mobilization
  • Gastrocnemius/Soleus Stretch – 1 set @ 30 sec
  • Kneeling Hip Flexor Stretch – 1 set @ 30 sec
  • Adductor stretch – 1 set @ 30 sec
  • Posterior joint mobilizations at the ankle – 90 seconds

Step 3: Increase neurological drive to hypotonic tissue – ~ 6 minutes:

• Exercise: Isolated Strengthening or positional isometrics
  • Resisted Ankle Dorsiflexion – 2 sets x 15 reps (slow) (2 minutes)
  • Resisted Hip Abduction and External Rotation- 2 sets x 15 reps (slow) (2 minutes)
  • Resisted Hip Extension – 2 sets x 15 reps (slow) (2 minutes)

Step 4: Integrated Dynamic Functional Movement – ~ 3 minutes

• Box step-up with overhead dumbbell press – 2 sets x 15 reps (slow)

Beyond the correction of movement dysfunction there are alternatives to treat running injuries which are effective and gaining popularity. This table highlights a few.

Prolotherapy	This has been around since the late 1800’s, but has since become popular. The basis of prolotherapy is that it expedites healing by increasing fibroblastic activity and collagen repair.
Autologous Blood	Blood is the medium that carries tissue repairing materials to injury sites. However, sometimes, blood cannot deliver adequate amounts of material to the injured area. Thus, injections directed right at the injury site deliver tissue repairing material.
PRP	Like autologous blood, Platelet Rich Plasma (PRP) is injection of a concentrated mix of tissue repairing blood components, specifically platelets, which facilitate tissue repair healing.
Bone Marrow Aspirate Concentrate	Despite the negative press and belief that stem cells are only derived from an unborn fetus, stem cells do come from other sources – such as bone marrow. By taking stem cells from bone marrow and injecting in to damaged areas will facilitate tissue repair.
ESWT	Extracorporeal Shock Wave Therapy might best be known as lithotripsy. Lithotripsy is a procedure in which sound waves blast and destroy kidney stones. ESWT is the use of sound waves to destroy calcific tendons and ligaments.

I prefer preventing and rehabilitating injury through correcting neuromuscular inefficiencies and dysfunctional movement. The problem with the above treatments is that they are treatments. If an injury is caused by dysfunctional movement patterns and those patterns are not corrected it is likely the above treatments will simply serve as a Band-Aid because the true problem was not fixed.

If the person(s) responsible for the Boston Marathon bombing were looking to put fear in people, they chose the wrong population to target. Runners are the most stubborn and prideful athletes. No means yes, and yes means do more. If you took a graphical representation of marathon registration numbers from last night through the end of this week I would bet you’d find a spike, rather than a decline. Social media is exploding with a rise of the runner. A quote from a friends Facebook page: “If you’re trying to defeat the human spirit, marathoners are the wrong group to target” –unknown. Other movements like, wear a race shirt tomorrow, donations, and wear yellow and blue (Boston Marathon colors) have already begun. So, thank you runners for inspiring this blog post!

Recommended Readings for Health and Wellness Geeks: March, 2013

Each day we are bombarded with new data. My goal is to share a breakdown of what I have discovered and read this past month. There is a little something for everyone here. How do I choose which articles to share? Is it clinically relevant? Does the story share something new or raise an interesting question? Most studies have some internal flaw that can be poked and while I try to only share those having high quality, my number one goals is to share something unique, progressive or surprising.

Published research:

In the recent release of The American Journal of Clinical Nutrition there is a good article supporting the benefits of a high-protein breakfast. Data reveals that a high-protein diet alters ghrelin and peptide YY concentrations subsequently leading to decreased appetite and also curbed late night snacking. Is this study perfect – no. But it is pretty darn good – Yes. I have been blogging on this topic for sometime. Where, when and why did the public begin thinking high protein intake is unhealthy? Did you know quality of protein is measured by how it compares to egg protein? That is because the protein in egg, albumin, has near perfect amino acid distribution. Yet many consider eggs bad.

Here is another topic area I have been yapping about for some time – risk factors for hamstring strains. This systematic literature review was first published online and is now in print in the latest edition of the British Journal of Sports Medicine. This SLR included 34 articles for review, which is a pretty good number to include. Unfortunately, only 1 evaluated hip extension strength. Three found decreased hip extension ROM measures indicating shortened hip flexors. It baffles me as to why studies do not look at glute weakness and hip flexor tightness as a risk factor for hamstring strains. I’ve written about this and hope someday a good study will come out and study the correlation.

Mild Traumatic Brain Injury – MTBI is getting a lot of media attention lately and rightfully so. NFL labor union disputes and an enormous amount of published research has athletes and parents taking MTBI seriously. If that wasn’t enough, Junior Seau’s suicide was linked to depression secondary to chronic TBI. In the Archives of Physical Medicine and Rehabilitation, April 2013 issue, an article discusses depression after TBI. It’s a nice short quick-hitting synopsis, with full-text available.

Website finds:

I subscribe to daily email updates from ScienceDialy. Two or three times per week they share something good that I get caught reading. Two articles they shared link positive benefits of Vitamin D. One shows that Vitamin D replacement improves muscle efficiency and another found Vitamin D may lower diabetes risk in children. Now I am not advocating to go overboard on Vitamin D, but I am saying drink Vitamin D fortified milk and cereals and get outside in the sun to ensure you are getting adequate vitamin D.

ScienceDaily also had an write-up that I loved regarding foods to help fight inflammation. The article states citrus fruits, dark leafy green vegetables, tomatoes, and foods high in omega-3s, such as salmon are anti-inflammatory foods. Notice none of these foods are grains, breads and/or pasta. All are earth foods and not processed. This supports and is similar to blogs I wrote previously: how the US Food Guide Pyramid and MyPlate could be to blame for our chronic disease epidemic, another which is very similar linking arthritis and osteoarthritis to diet. Finally two of my most popular posts written Stop Destroying Your Body and Is Your Diet Making You Sick discuss the link between diet and disease.

Must Read Blogs:

There are so many smart people out there and I enjoy learning from them all. Here are some good blog posts from this month.

The first is from Sport Injury Matt (@SportInjuryMatt – twitter handle). He had two posts about foot mechanics and foot wear. Part I shares good crucial information on foot mechanics. Part II of this post talks about what one should run in and considerations when selecting certain shoes.

My good friend Jay Barss (@sportsrehabtalk – twitter handle) is new to the blog and twitter world. He is a smart dude and deserves some following. His most recent post talks about the a new perspective on management on patellofemoral pain management. As we all know, correction of faulty movement patterns is critical in management of the oft-diagnosed PFPS.

Last is a series posted by  Allan Besselink (@abesselink – twitter handle). If you have not followed Allan’s blog I highly recommend it. In fact his blog was recently nominated as top choice for health and wellness. Everything he posts is high quality. I particularly liked his three-part series titled the Low Back Pain Paradox. Low back pain effects 80% of the adult population and Allan does a great job covering all the bases in Part I, Part II, and Part III.

Stay healthy and well!

Mechanotransduction: Why Does Rehabilitation Work?

You have an athlete with a stress fracture. The physician prescribes active rest and places the athlete in a non-weight bearing boot. Sound familiar? Suppose I told you the better option is to place some load on that bone and non-weight bearing is not recommended. Would you think I am nuts? Maybe I can convince you otherwise. Let me explain but, before you read the next paragraph and decide to leave the page, bear with me. What follows this introductory piece may provide insight to further understanding of injury pathophysiology and could revolutionize the future of rehabilitation science.

In January 2013 the Annals of Human Genetics published an article that demonstrated Achilles Tendinopathy is associated with gene polymorphism (Abrahams, et al., 2013). I am not a geneticist by any stretch of the imagination, so pardon my basic explanation. COL51A is a gene that encodes the development and organization of Type V collagen. Type V collagen is a collagen that is distributed in tissues as a component of extracellular matrix and composed of one pro alpha 2 (V) and two pro alpha 1 (V) chains. This collagen can be found in ligaments, tendons, and connective tissue. COL51A plays an integral role in development and maintenance of connective tissue. Abrahams, et al. (2013) demonstrated that polymorphisms occur in the COL51A gene causing altered structure of collagen resulting in tendionpathy.

I state the aforementioned because it is time for athletic trainers to begin taking a deeper look at pathophysiology and more importantly, to utilize this understanding in the development of our rehabilitation and treatment guidelines. Some of you may already be cognizant of this, but these revolutionary approaches to treatment and rehabilitation are already coming to light. Let me introduce the concepts of cellular signaling, mechanotransduction, and mechanotherapy.

Mechanotransduction and the Processes of:

Mechanotransduction ( described by Khan 2009) is the process whereby mechanical load initiates biochemical signals that leads to gene upregulation, protein synthesis and ultimately structural change (Khan 2009). Load causes perturbation to cells that initiates signaling pathways, where mRNA is sent to the endoplasmic reticulum for gene encoding. If you recall from college physiology, proteins are created by ribosomes following this transcription. These proteins are the new collagen and are extruded from the extracellular matrix and delivered to the damaged tissue. This is why eccentric training heals tendinopathy.

This process is not limited to damaged connective tissue. The mechanical load induces cellular signaling in all tissue – nervous, muscular, connective, bone and cartilage (Khan, 2009). In muscle, load stimulates upregulation of mechanogrowth factor and ultimately hypertrophy. Chrondrocytes are sensitive to load and are fed through load. Load applied to osteocytes deep within bone stimulates bone lining cells and facilitates healing to expedite fracture repair.

Review of cool supporting studies: 

Joseph, et al., (2012) stated that tendinopathic tendon is less stiff and loses ability to transfer energy. Joseph goes on to state that load creates a viscoelastic response in the Achilles tendon that increases stiffness and decreased hysteresis. Fragala et al., (2011) demonstrated leukocyte β₂-adrenergic receptor expression changed in response to heavy resistance exercise. Flück, et al., (2008) evaluated tenascin-C,  a protein responsible for tissue remodeling that is expressed only in damaged tissue and regulated by mechanical load. They found that mice deficient of tenascin-C had diminished muscle tissue healing and conclude that tenascin-C is needed for reducing and healing of musculoskeletal injuries.

Scott, et al., (2008), demonstrated physiological load induces an osteogenic response that stimulates anabolic cellular activity in bone. In the Journal of Sport Rehabilitation – published by the one and only Human Kinetics – stated “the notion that deep friction massage may provide mechanical stimulation for healing is intriguing, especially given the context in which Cyriax, advocated this “mechanotherapy” as early as 1984…. While this is difficult to study in a human model, there is some poignant animal evidence that tendon massage indeed stimulates tissue adaptation at the cellular level.” (Joseph, et al., 2012). Durieux, et al., (2009) assessed regulation of focal adhesion kinase in mechano-regulated differentiation of slow-oxidative muscle. Focal adhesion kinase initiates cellular signaling and ultimately migration of cells and is required during development. The authors found that focal adhesion kinase is part of the signaling pathway that governs repair of striated muscle.

Conclusion:

Is a non-weight bearing walking boot the best treatment option for a stress fracture? It appears it is not. Based on the data discussed here, the practitioner must utilize an intricate balance between rest and mechanical loading of bone to obtain optimal healing. In order to heal damaged tissue we must use exercise as a repair stimulus – mechanotherapy.

The body of evidence exists and is continuing to grow. It is recommended athletic trainers and rehabilitation specialists take time to understand the pathophysiology of injury and the biochemical processes that elicits healing. In the very near future you will need to understand the biochemical events that promote tissue repair. The knowledge gained will dictate rehabilitation protocols needed for specific injuries.

References:

Abrahams Y, Laguette MJ, Prince S, and Collins M. Polymorphisms within the COL5A1 3′-UTR That Alters mRNA Structure and the MIR608 Gene are Associated with Achilles Tendinopathy. Ann Hum Genet. (Epub – ahead of print) Jan 2013.

Khan, K M, and Scott, A. Mechanotherapy: How Physical Therapists’ Prescription of Exercise Promotes Tissue Repair.  Br J Sports Med. 2009;43:247–251.

Joseph, MF, Lillie, KR, Bergeron, DJ, and Denegar, CR. Measuring Achilles tendon mechanical properties: A reliable, noninvasive method. J Strength Cond Res. 26(8): 2017–2020, 2012.

Fragala, M. S., Kraemer, W. J., Mastro, A. M., Denegar, C. R., Volek,  J. S., Hakkinen, K.,  Anderson, J.M.,  Lee, E. C., and Maresh, C. M. Leukocyte β₂-Adrenergic Receptor Expression in Response to Resistance Exercise. Med. Sci. Sports Exerc. Vol. 43, No. 8, pp. 1422–1432, 2011.

Fluck M, Mund SI, Schittny JC, Klossner S, Durieux AC, et al. (2008) Mechano-regulated tenascin-C orchestrates muscle repair. Proc Natl Acad Sci U S A 105: 13662–13667.

Scott, A., Khan, K.M.,  Duronio, V, Hart, D.A. Mechanotransduction in Human Bone In Vitro Cellular Physiology that Underpins Bone Changes with Exercise. Sports Med. 2008; 38 (2): 139-160.

Joseph, MF, Taft, K, Moskwa, M, and Denegar, CR. Deep Friction Massage to Treat Tendinopathy: A Systematic Review of a Classic Treatment in the Face of a New Paradigm of Understanding. Journal of Sport Rehabilitation. 2012, 21, 343-353.

Durieux AC, D’Antona, G, Desplaches, D,  Freyssenet, D, Klossner, S, Bottinelli, R, and Fluck, M. Focal adhesion kinase is a load-dependent governor of the slow contractile and oxidative muscle phenotype. Jof Physiol.  2009;587:14. 3703–3717.

Hate “Cardio”? Me Too, But “Cardio” Doesn’t Have To Suck

For many, “cardio” sucks. Running – the  boring monotonous “fat-burning” exercise that is nothing more than audbile thud, thud, thud of a foot slap whilst staring at mindlessly at CNN Breaking news on the overhead TV monitors. Some meathead gets on the machine next to you and insists on going 1% steeper grade and .1 MPH faster. You try the elliptical, which has absolutely zero relationship to how we move everyday, unless you have discovered an amazing pair of Back To the Future-esk sneakers that allow you to air pedal instead of walk. Then there are those who need upper body rest and choose to bike. Or better yet, if you are really tired you can choose the recumbent bike that is perfect for people who want to lie down while exercising.

For the “cardio” lovers out there; I get it, “cardio” can be awesome and burn calories. I get there are many training programs. So, before you get on your soapbox to scream “CARDIO ROCKS”; [relax, breath - this might sting] not everyone shares  your opinion. For many “cardio” sucks.

By now you have likely noticed the quotes around “cardio”. People describe “cardio” as running, stairclimber, elliptical, biking or swimming.  It’s not. Cardio – short for cardiovascular or cardiorespiratory and synonymous with aerobic exercise – is simply the act of raising your heart rate for an extended period of time (> 5 minutes) without allowing it to recover.  That’s right, anything you do to increase heart rate for the duration of the workout is technically cardio. The best way to do this is by doing a circuit training program.

Circuit training is simply a series of exercises that are performed for a set of repetitions or time frame with minimal rest periods (<40 seconds) in between each exercise. The short rest period is the crucial component as it will not allow your heart rate to recover, which is why circuit training can be a cardio or aerobic exercise.

Designing a circuit program is easy. Pick a series of 5-10 exercises. Alternate the exercises between upper body, lower body and total body. Design your workout with 1 minute increments that have an “on” time (period of doing the exercise) and an “off “time (period of rest). For example, exercise for 30 seconds, rest for 30 seconds. Here is what a program might look like if doing a 30 on/30 off:

* Push-up (do for entire 30 seconds)
* Rest (30 seconds) During your rest get ready for the next exercise.
* Ball squat
* Rest
* Bent over row
* Rest
* Step-up with over head press
* Rest
* Ab crunches
* Rest
Repeat that cycle 5 times. Your total workout time would be 25 minutes.

You can make the circuit harder or easier by manipulating the rest time or changing the intensity of the exercise. Here is a harder circuit program using the same 30 on/30 off time, but with more intense exercises:

* Plyometric Push-up
* Rest
* Squat Jump
* Rest
* Medicine ball slams
* Rest
* Burpees
* Rest
* Speed ladder
* Rest
Repeat that cycle 5 times. Your total workout time would be 25 minutes.

Need it more intense? Repeat the cycle 7 times. Still not enough – decrease your rest time so “on” time is 40 or 45 seconds and the rest period is 15-20 seconds. Trust me, if you can do the above workout with a 45/15 on/off time for 7 cycles, you don’t need to read this. You should be competing at the next Ironman.

The beauty of circuit training is that it defeats monotony. You can plug any exercise in to the circuit routine. You can do this program 5 days per week and never do the same exercise twice. Use your imagination.

“But will I get the same calorie burn as I would with running?” No, you will have more!! Exercises in a circuit program are more intense than a steady state cardio. Your heart rate will shoot up during the “on” time creating a higher peak heart rate. Since the rest period is short, you will also have a higher average heart rate. Higher heart rate = higher caloric burn.

More positives; because the intensity is higher you can achieve the same caloric burn in less time. Which would you rather do: spend 60 minutes to burn 400 calories on an elliptical or 25 minutes doing a variety of things? Want more – your circuit program has weight training in it. Not only are you getting cardio, you are lifting – two birds, one stone.
Finally, no blog of mine could be mine without a little bit of geeky-ness. The concept of EPOC or excess post-exercise oxygen consumption. We need oxygen to feed our cells and produce energy. When you perform high-intesity exercise – like that in a circuit program – you create an oxygen debt. In a sense your body is starving for oxygen. After exercise your body must continually consume oxygen to make up for the debt. This is metabolism and extended caloric burn. With a circuit program the oxygen debt is greater than that of traditional “cardio”. Thus, you continue to have increased metabolism for 12-24 hours after the exercise. With a slow steady state “cardio” exercise, your metabolism is done after 2-4 hours.

See, cardio doesn’t have to suck. However, if you are hell-bent on strolling along on that elliptical while reading 10 chapters of the latest John Sanford novel – have fun.

Knee Pain? Ignore it; Fix the Hip!

I have posted on this topic many, many times. Unfortunately, many still revert to antiquated rehabiltiation protocols. Thus, I feel compelled to keep talking about it.  If you or a client has knee pain focus on the hip, not the knee. There is so much data out there on linking decreased glute strength to knee pain. A weak or inhibited glute medius is unable to control femoral internal rotation and obligatory knee frontal plane motion.  These motions are a primary cause in knee pain – traumatic and acute. Today I discovered two, recently-published, systematic reviews to prove my point.

The first review examined 47 studies which looked at factors causing Patellofemoral Pain Syndrome  (PFPS) (1). This review identified decreased muscle strength for hip abduction and hip external rotation as an important factor associated with the cause of PFPS. The pooled data also found increased Q-angle and sulcus angle to be factors – both of which have been linked to muscle imbalance.

The second systematic review was more specific by evaluating gluteal muscle activity – via EMG – and PFPS (2). The authors identified ten studies to be included in their review, with six of these studies considered to be high-quality and eight studies having a score of 8 or higher on the Downs and Black scale. The authors conclude there is moderate to strong evidence linking delayed or short Glute medius muscle activity to PFPS. The authors also state, “If gluteal muscle activation is delayed, frontal and transverse plane hip motion control may be impaired, leading to increased stress on the PFJ and subsequent symptoms associated with PFPS.”

Rehabilitation practitioners should note this when developing rehabilitation programs. Specifically targeting glute weakness and inhibition will limit hip internal rotation and obligatory knee frontal plane motion. Correcting faulty movement patterns will allow for optimal neuromuscular recruitment and joint kinematics, ultimately relieving or preventing pain.

If you are wondering which exercises will target the glute medius look at the study published in the recent JOSPT (3) and my recent blog titled “The Glute vs TFL Muscle Battle: Proper Exercise Selection to Correct Muscle Imbalance”. The data represented in the JOSPT article demonstrate the bilateral bridge, unilateral bridge, side step, clam, squat and two quadruped exercises are best for activating the glute medius.

Are you ready to change your rehabilitation program?

References:

1. Lankhorst NE, Bierma-Zeinstra, SMA, and van Middelkoop, M. Factors associated with patellofemoral pain syndrome: a systematic review.  Br J Sports Med.  2013;47:193–206.
2. Barton CJ, Lack, S, Malliaras, P, and Morrissey, D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013; 47:207–214.
3. Selkowitz, DM, Beneck, GJ, and Powers CM. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther. 2013; 43(2):54-64.