TENNIS RELATED INJURIES & HOW YOUR DAILY WORK MAY BE SIMILAR

While reading up on some upper extremity injuries associated with sport, I came across this piece from Epidemiology of musculoskeletal injury in the tennis player. Based on information found the authors are hypothesizing that “teaching the topspin serve at a young age may put the young tennis player at increased risk for back pain and/or injury.” It is thought that “early introduction to the topspin serve may be associated with the development of spondylolysis and/or spondylothesis in elite-level players.”

This particular piece of research goes into other injuries associated with tennis such as lower extremity pains, association with volume of play, age and sex, skill level and even racquet grip position. 

Racquet grip position is another one I found to be very interesting as different grips have been associated with different overuse injuries.

• Ulnar sided injuries (extensor carpi ulnaris tendonitis and triangular fibrocartilage complex pathology) were significantly associated with a Western or Semi-western grip

• Radial sided injuries (flexor carpi radialis tendonitis, De Quervain's tendinopathy and intersection syndrome) were more common with Eastern grip.

With this information regarding tennis racquet holds being associated with different overuse injuries, we can see how this may relate to daily work , job dependent. Below you can see the photo of how this individual holds a rod, what you don’t see is that they have a large GPS unit above that needs to be stabilized, similar to stabilization needed when hitting a tennis ball. Some different wrist and hand positioning on this rod may pre- dispose this individual to these same overuse injuries.

Which tennis grip style is most like this positioning?

Osteoporosis Part 4: It's Complicated. How You Get It, What You Do About It…

In this next part of the ongoing discussion regarding osteoporosis I wanted to talk about diagnosis and the confusion that surrounds it.

Standard medical diagnosis of osteoporosis or osteopenia is done by a low-dose radiation x-ray of the hip and spine call a DEXA scan. Please note that plain film x-rays are not a good way to screen or establish a firm diagnosis of osteoporosis although it will often indicate some issues with bone mass that need to be followed up with the appropriate diagnostics.

The results of a DEXA scan are reported as the T score and Z score in both the hip joint and in the lower lumbar spine. A mild decrease in bone mass compared to what is considered standard will result in the diagnosis of osteopenia while a more significant decrease of bone mass will result in a diagnosis of osteoporosis. The scoring associated with a diagnosis of osteoporosis is also usually associated statistically with a certain fracture risk over the following 10 years.

As a patient you need to understand that there are some caveats and limitations associated with how you interpret your own DEXA scan results.

- The DEXA scan has a certain margin of error. If you are close to a cutoff of osteoporosis or osteopenia this could be significant.

- The margin of error can be amplified when comparing repeat scans by having the procedure performed on a different machine or by a different technician. In some instances this could be significant and make the interpretation of comparative scans difficult. If you're tracking osteoporosis response to treatment whether medical or integrative, you really should always be getting your scan on the same machine at the same facility.

- There are some issues with the spine and hips that can give you a false positive or negative readings, most commonly positive readings. This is especially true for people who have some degree of degenerative disc disease with bone spurs, more advanced degeneration, or congenital anomalies of the lumbosacral spine such as a spondylolisthesis. If this is a significant concern for false-positive, a quantitative CAT scan would be the definite testing but it involves more radiation.

- There is some question about the validity of a single scoring system applied to different ethnic groups, as well as in women with very small frames, whose bone mass may be naturally and sufficiently lower than their counterparts. It is also true that women with very high BMI may look like they have adequate bone mass but in reality the bone density may not be sufficient to protect them from fracture because of the increased demands associated with the extra weight.

- The DEXA scan measures the raw amount of bone mineral, however it does not measure the quality of the bone architecture which is very important for fracture prevention. This is not to invalidate the benefit of a DEXA scan but to realize that there is still some question about whether or not current osteoporosis drugs improve bone density without concurrently improving architecture, meaning that we may get a false sense of security against fracture risk long-term.

- Finally and possibly most importantly the DEXA scan only measures one snapshot of your bone mass in time. Unless you have comparative scans you have no idea if you are currently losing bone, are in the process of starting to lose bone, or have previously lost bone mass but have plateaued. This is why I strongly suggest that every woman has a baseline DEXA scan prior to menopause or at the onset of menopause for future comparison and good treatment decision.

- Based on the above, it can be extremely useful to couple the DEXA scan with other testing that may give you more real-time information about bone metabolism and turnover. One such test which is mostly used in integrative health practices rather than allopathic traditional medical care would be a urinary D-Pyrilink excretion test. We will talk more about it in our next segment.

Taping

Recently I’ve been getting more questions regarding taping, different techniques and the differences between tapes. The main tapes I have become familiar with are white tape or athletic taping or strapping. This is the tape that most people are familiar with on ankles in football. This tape is mostly used for support and structure. I don’t tend to use this tape very often in the clinic. Kinesiology tape is the next most common tape people know. This tape tends to be seen on athletes everywhere and has been around for awhile. I tend to use kinesiology tape mainly for some short term movement facilitation. Often patients will note feeling some additional support. The last tape I’m going to write about is a “newer” type of tape, dynamic tape. This tape is reported to be more of a biomechanical tape. I use this a lot in clinic for offloading techniques. Meaning when an injury occurs many times some of the load or weight needs to be taken off the injured tissue in order to allow for optimal healing. There are ways we can use this tape to assist in providing some of that offload as well as other in office techniques to assist in the recovery.

Osteoporosis Part 3: It's Complicated. How You Get It, What You Do About It…

A special note about osteoporosis and diet, because it is an area of high confusion.

For most folks, the connection between diet and osteoporosis is reduced to getting a defined amount of calcium in your diet or through a supplement. Our bodies do need a minimal amount of absorbable calcium but there is much more to it. And supplements need to be in the right form to be of value (that will be in a later blog.) ALSO, REMEMBER THAT NUTRIENT INTAKE AND BONE AVAILABILITY ARE DEPENDENT UPON PROPER ABSORPTION IN THE GI, WHICH CAN BE IMPAIRED BY A VARIETY OF CHRONIC GI PROBLEMS AND MANY COMMON MEDICATIONS.

CALCIUM: There is individual variation of how much one person needs, but retrospective population studies of folks who have eaten a traditional diet shows they were getting anywhere from 800-1600 mg. Calcium sources are probably the most important factors. Calcium from whole foods that contain some of the other nutrients that are incorporated in bones are the best. For people who have good tolerance to dairy products, cultured dairy (cheese, yogurt) can give you several hundred milligrams in one serving. The naturally aged, more artisan cheese also provide vitamin K2, which is important for directing calcium into bones rather than soft tissues and arteries. Among the non-dairy foods, the highest content will be from animal foods than have bony residues: bone-in fish (canned salmon and sardines for ex), bone-in slow cooked meats, and traditional both broth. I grew up with traditional foods and we never wasted any bones. A lot of folks make their own bone broth, but if you do not like your house smelling like soup all the time, you can purchase high quality broth in many natural food stores (Kettle and Fire brand for ex). Leafy green veggies and the brassica family (cabbage, broccoli,) also have a decent content, but the bio-availability is low so you need to eat them lightly cooked and preferably with a little fat. Otherwise, there are lots of foods that have a small amount of calcium that add up, so a varied whole foods diet will give you a few extra hundred mg per day.

PHOSPHORUS: Needs a special mention. Not because it is often deficient in folks diet. Phosphorus is a common additive in processed foods and sodas and not labeled as such. Phosphorus in processed foods is in such concentration that it upsets the balance of calcium and phosphorus in the intestines, causing salt precipitation of the two minerals together and preventing them from being absorbed. Bottom line, any processed food will negatively affect your calcium balance.

PROTEIN: Most of the scaffold of your bone is made out of collagen protein. Most of us need about 2/3 of our body weight in grams (150 lbs = 100 gr). You may need more in circumstances like illness, pregnancy, and intense physical activity. Protein needs to come from both plant and animal foods. There is a misconception floating around that animal protein make you lose calcium in your urine. That is not correct. Your body excretes extra calcium it does not need in the urine and animal protein significantly increases the rate of calcium absorption in the intestines, thus leading to a little more spillover in the urine. Animal protein should ideally include some of the soft tissues like skin and tendon because of the collagen amino acids that is incorporated in bones.

FAT SOLUBLE VITAMINS: Your body needs ALL fat soluble vitamins, not just vitamin D3. Vitamin D3 is ideally produced in your skin when cholesterol rings are converted by exposure to UV light. So you need some good sources of cholesterol and some time outside showing a little skin. Vitamin A is often the forgotten fat soluble vitamin, you need both plant and animal sources for optimal status. Vitamin K2 is also not getting enough attention for its role in balancing calcium deposition away from soft tissues and into bones. Highest levels are found in cheese, and fermented products (including some that are not common in the non-ethnic US diet). Fat soluble vitamins tend to be low in patients on vegan diets and on meds that limit the rate of fat absorption like statins

MINERALS AND TRACE MINERALS: Magnesium, zinc, and boron are all important in bone metabolism. Whole foods diets will usually give you enough, but for some folks it may need to be supplemented, especially magnesium.

Sports Nutrition- Hydration Part II

So in Part I we discussed the rainforest and nutrient dense soils, we are going to keep building off of that here in Part II. 

When your body is being nourished, it can actually move water. We want to be able to move water in and across cell membranes. When we think of water moving, we also have to think about water staying. Think of stagnant water that hasn’t had any movement, it usually get pretty gross, hence why not only do we need to be hydrated, but we need nutrients to be well nourished in order to move the water that is inside of us.

Many people have heard “muscles weigh more than fat” and that is not wrong. Muscle also contains 70-75% water and are generally considered storage components for nutrients. Meaning more muscle is storing more nutrients and what did we find out in Part I, “water follows nutrients”. Now, unlike muscle, fat is able to store toxins and it is actually only 10-15% water weight. 

I want to touch a little bit on fascia hydration. In previous Soft Tissue blogs I talk about fascia so if you want more on that feel free to check those ones out. 

So, in this Hydration for Performance talk by Todd Stableton that I had listened to it was brought up that fascia is the delivery mechanism for fluid. Meaning that when I have discussed soft tissue and fascia binding and if you have ever had some additional soft tissue care, your provider usually reminds you to drink some extra water that day, because these bindings are not allowing for the delivery mechanism to flow, the water flow is being stopped. There is a blockage in the system. 

It all comes together, being hydrated isn’t just drinking enough water, but also having the nourished system to hydrate within the cells and keeping fascia unbound and flexible in order to keep the delivery mechanism flowing. It all comes full circle. 

As it begins to warm up here in MN, think about how you are going to keep yourself hydrated.

Osteoporosis Part 2: It's Complicated. How You Get It, What You Do About It…

Last week I reviewed the basics on bone composition and metabolism. Now I would like to review some basics about some factors that both positively and negatively influence bone mass.

Positive

• Weightbearing activity and resistance training improve both the quantity and architecture of bone. Most female patients make the mistake of not incorporating strength training in their routine. Walking is good for many things but not sufficient for stimulating and maintaining bone mass.

• Adequate intake of ALL bone building nutrients: complete protein (including animal protein which increases calcium uptake in the intestines): all minerals (calcium, magnesium, phosphorus, zinc and rare minerals like boron): Fat soluble vitamins like vitamin D, K2 and A.

• Adequate balance of hormones: estrogen, progesterone, testosterone, DHEA, cortisol, and parathyroid

• Close to optimal weight/BMI

Negative

• Inadequate dietary intake or balance (more on that later)

• Digestive malabsorption from various sources (very often missed!)

• Insufficient physical activity and resistance training

• Obesity/High BMI: although obese individuals tend to have a slightly higher bone mass, it is proportionately not enough for the extra weight the bone has to carry

• Being significantly underweight

• Many medications: steroids, estrogen blockers (for hormone positive breast cancer), anti-seizure medications, many anti-acid medications, progestin only birth control implants and injections (especially in teenage women).

• Hormone Imbalance: estrogen deficiency, thyroid overmedication, hyperparathyroidism

Sports Nutrition- Hydration Part I

I was recently listening to a talk from Todd Stableton on Hydration and Performance, the following is what I have taken away and wanted to communicate with each of you.

Hydration is so much more than just drinking your recommended amount of water daily. Sure, it’s a good start, but to truly have good hydration within your systems more is needed. Todd Stableton mentions hydration being the consequence of a good lifestyle, similar to posture.

The term “to water” actually means to encourage health and growth. Just as you were to water your plants, for them to be healthy and grow. 

We can use water as an electrical conductor and us as humans are born at about 70% water. So, that can make us electrical conductors or as Todd said “the more hydrated somebody is, the more potential they have for energy”. Cool. 

So, how do we get hydrated? Water follows nutrients, right? If we look around us and look at soil and dirt, the most hydrated soils are in the rainforests which have the largest amounts of nutrients. Or the fields around us that are more hydrated than deserts but less hydrated than rainforests, must have some nutrient content to them. Muscles can be storage components for nutrients while fat is unable to store nutrients, but is quite able to store toxins. Meaning as people are raising their fat percentage, they are raising their dehydration levels or lowering their hydration. 

You can probably begin to see how accurate the first statement is with “hydration being the consequence of a good lifestyle”.

We want to be drinking nourishing water and can do so by adding back some minerals like a pinch of pink Himalayan sea salt.

Will be continued in Sports Nutrition- Hydration Part II , stay tuned.

Osteoporosis: It's Complicated. How You Get It, What You Do About It…

I have been contemplating writing a blog series about this topic but found the task too daunting for too long. For most patients I talk to, osteoporosis boils down to calcium, and biphosonate medications. The development and maintenance of bone mass is complex, the diagnosis of bone mineral deficiency is nuanced, the efficacy of medication treatment is not as clear cut as we would like. No wonder patients (and sometimes myself) have a “deer in the headlight“ look on our face when discussing the topic.

In this first part I simply want to establish a few simple facts about bone biology.

• Bones are made of primarily collagen protein and minerals. Of those minerals, calcium is the primary but not the only one. (magnesium , phosphorus, boron etc.)

• The resistance of a bone (“strength”) to fracture depends upon not only the total amount of bone (bone density), but also and very importantly the internal scaffolding and architecture of how the bone is organized to resist trauma .

• Bones are not static. They are in a constant state of remodeling over time, both in quantity and in architecture. We have cells that specializes in depositing bone (osteoblasts) and cells that take it down (osteoclasts). The latter are the target of most medications, by preventing the resorption of bones.

• Our bone mass will peak in early adulthood. However, you can still do a lot to avoid losing bones at an excessive rate over time.