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March Feature: Lower Back Pain: Is It A Hip Or Spine Problem? Guidance For A Correct Diagnosis

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“Lower Back Pain: Is It A Hip Or Spine Problem? Guidance For A Correct Diagnosis”

 

Low back pain is one of the most common aches, as 80 percent of the population will experience it at some point in their lives, according to statistics from the American Chiropractic Association (ACA). What’s more, the organization says that at least $50 billion is spent each year on treatment for the ailment, which is also one of the most common reasons for missed work.

One problem with treating back pain is that there’s overlap between back and hip problems, according to hip specialist Trevor Murray, MD, in a story on the Cleveland Clinic website.

A new article from the American Academy of Orthopaedic Surgeons attempts to address groin, thigh and knee pain associated with the back, hip and spine.

According to the article, groin pain or problems getting in and out of a car, are linked to a problem with hips, while butt and back problems are tied to the spine. But those with “hip-spine syndrome” have pain in both areas, making it hard to determine the source of the problems.

“In these instances, similar or overlapping symptoms may delay a correct diagnosis and appropriate treatment,” says article author Afshin Razi, MD, in a statement.

The article advises those experiencing lower back pain to see a doctor for a comprehensive examination to assess qualities like gait, range of motion and posture.

Diagnosis is also a problem because many treatment centers are so specialized. For example, hip surgeons look only at hip problems, says Dr. James Kang of Brigham and Women’s Hospital, in a post on the hospital’s blog. Kang was not associated with the study but serves as chairman of the department of orthopaedic surgery at Brigham and Women’s Hospital.

Rehabilitation and physical therapy are typical treatments for hip and spinal disorders, but can be more complex if a patient is nonresponsive to those options. However, Kang recommends lifestyle changes like weight loss and aerobic activity like swimming and biking for improved hips, spine and back health.

 

Matthews, Melissa. “Lower Back Pain: Is It A Hip Or Spine Problem? Guidance For A Correct Diagnosis.Medical Daily 7 February 2017.

March Feature: Lower Back Ache? Be Active and Wait It Out, New Guidelines Say

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“Lower Back Ache? Be Active and Wait It Out, New Guidelines Say”

 

Dr. James Weinstein, a back pain specialist and chief executive of Dartmouth-Hitchcock Health System, has some advice for most people with lower back pain: Take two aspirin and don’t call me in the morning.

On Monday, the American College of Physicians published updated guidelines that say much the same. In making the new recommendations for the treatment of most people with lower back pain, the group is bucking what many doctors do and changing its previous guidelines, which called for medication as first-line therapy.

Dr. Nitin Damle, president of the group’s board of regents and a practicing internist, said pills, even over-the-counter pain relievers and anti-inflammatories, should not be the first choice. “We need to look at therapies that are nonpharmacological first,” he said. “That is a change.”

The recommendations come as the United States is struggling with an epidemic of opioid addiction that often begins with a simple prescription for ailments like back pain. In recent years, a number of states have enacted measures aimed at curbing prescription painkillers. The problem has also led many doctors around the country to reassess prescribing practices.

The group did not address surgery. Its focus was on noninvasive treatment.

The new guidelines said that doctors should avoid prescribing opioid painkillers for relief of back pain and suggested that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga. Doctors should reassure their patients that they will get better no matter what treatment they try, the group said. The guidelines also said that steroid injections were not helpful, and neither was acetaminophen, like Tylenol, although other over-the-counter pain relievers like aspirin, naproxen or ibuprofen could provide some relief.

Dr. Weinstein, who was not an author of the guidelines, said patients have to stay active and wait it out. “Back pain has a natural course that does not require intervention,” he said.

In fact, for most of the people with acute back pain — defined as present for four weeks or less that does not radiate down the leg — there is no need to see a doctor at all, said Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University in Portland, Ore., and an author of the new guidelines.

“For acute back pain, the analogy is to the common cold,” Dr. Deyo said. “It is very common and very annoying when it happens. But most of the time it will not result in anything major or serious. ”

Even those with chronic back pain — lasting at least 12 weeks — should start with nonpharmacological treatments, the guidelines say. If patients still want medication, they can try over-the-counter drugs like ibuprofen or aspirin.

Scans, like an M.R.I., for diagnosis are worse than useless for back pain patients, members of the group said in telephone interviews. The results can be misleading, showing what look like abnormalities that actually are not related to the pain.

Measures that help patients get back to their usual routines can help along the way, as Sommer Kleweno Walley, 43, of Seattle, can attest. Last spring, she slipped on the stairs in her house and fell down hard, on her back.

“After a couple of hours I could barely walk,” she said. “I was in real pain.”

She saw a physical therapist, but the pain persisted. Eleven days later, she showed up at the office of Dr. Christopher J. Standaert, a spine specialist at the University of Washington and Harborview Medical Center. She expected to receive an M.R.I., at least, and maybe a drug for pain.

But Dr. Standaert told her an M.R.I. would not make any difference in her diagnosis or recovery and that the main thing was to keep active. She ended up getting anti-inflammatory medication and doing physical therapy. A few months later, her back stopped hurting.

It is surprising, some experts in back pain say, how often patients are helped by treatments that are not medical, even by a placebo that patients are told at the start is really a placebo.

Dr. Standaert cited a study in which patients with chronic low back pain were offered a placebo, and were told it was a placebo, along with their usual treatment — often an anti-inflammatory drug like ibuprofen or naproxen. Or, the patients remained with their usual treatment alone.

Those taking the placebo reported less pain and disability than those in the control group who did not take it. The placebo effect, although modest, was about the same as the effect in studies testing nonpharmacological treatments for back pain like acupuncture, massage or chiropractic manipulations.

Many people with chronic back pain tend to shut down, avoiding their usual activities, afraid of making things worse, Dr. Standaert said. Helping them is not a matter of prescribing drugs but rather teaching them to set goals and work toward returning to an active life, even if they still have pain.

“They have to believe their life can get better,” Dr. Standaert said. “They have to believe they can get to a better state.”

The question is: Will the new guidelines be adopted?

“Patients are looking for a cure,” said Dr. Steven J. Atlas, a back pain specialist at Massachusetts General Hospital, who wrote an editorial accompanying the article on the new recommendations. “The guidelines are for managing pain.”

Added to the problem are the incentives that push doctors and patients toward medications, scans and injections, Dr. Deyo said. “There is marketing from professional organizations and from industry,” he said. “‘We have the cure. You can expect to be cured. You can expect to be pain free.’”

Medical insurance also contributes to the treatment problem, back experts say, because it does not pay for remedies like mindfulness training or chiropractic manipulations which, Dr. Deyo added, “are not cheap.”

Even if doctors want to recommend such treatments, there is no easy referral system, Dr. Atlas said.

“It is much easier at Mass General to get a shot than to get a mind-body or cognitive behavioral therapy,” he added.

Dr. Weinstein has a prescription: “What we need to do is to stop medicalizing symptoms,” he said. Pills are not going to make people better and as for other treatments, he said, “yoga and tai chi, all those things are wonderful, but why not just go back to your normal activities?”

“I know your back hurts, but go run, be active, instead of taking a pill.”

Kolata, Gina. “Lower Back Ache? Be Active and Wait It Out, New Guidelines Say.The Washington Post 13 February 2017.

March Feature: More evidence that we need to stop sitting so much — especially men

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“More evidence that we need to stop sitting so much — especially men”

 

If you have a desk job, it is pretty easy to spend most of your day on your bum. Even after you punch the clock, chances are there will be more time sitting between your commute and the nightly intake of your favorite shows. You know you should at least walk a bit more during the day.

If you are like most people, it is difficult to get motivated. But recent research might push you in the right direction — especially if you are a man.

In a study published Thursday by the Centers for Disease Control and Prevention, researchers looked at the amount of time 4,486 men and 1,845 women spent sitting during work, school and at home. They examined obesity among participants, ages 20 to 79, by measuring the size of their waistlines and percentage of body fat. No matter the metric, the more men sat, the likelier they were to be obese.

“Men who sat more were more likely to be obese, and that held even when we adjusted for their fitness level,” said Carolyn E. Barlow, who led the research team at the Cooper Institute in Dallas. “The other risk factors that we looked at — cholesterol and glucose — were also not associated with sitting time. That was a bit surprising.”

The research team asked participants to report the frequency and duration of 11 types of physical activity, including walking, running and bicycling. Nearly half of the men reported sitting three-fourths of the day, while only 13 percent of women said the same. But even women who sat for long periods of time had lower levels of obesity than men, according to the study.

Researchers did not pinpoint a root cause for the higher rates of obesity in sedentary men, and said further research is needed to explore the relationship. Barlow said one limitation of the study is participants self-reported their activity level. Participants were also primarily white, generally healthy and well educated, making it difficult to apply the results to more diverse populations.

“We’re limited to some degree with the population who comes in because they’re all self-referred or corporate-referred patients,” Barlow said. “We definitely want to look at the changes in sitting time and how that associates with different risk factors among patients who come back to the clinic.”

The new findings build on a body of research that shows a relationship between sedentary lifestyles and increased risk for chronic conditions and premature death. One study in the Diabetes Research and Clinical Practice journal found a connection between prolonged sitting and Type 2 diabetes, which occurs when the body fails to use or make enough insulin to convert blood sugar into energy.

Another study from the University Health Network in Toronto concluded that people who sit too much every day are not only at risk of diabetes, but also heart disease, cancer and shorter life spans, even if they work out. People who exercise are at lower risk of developing those health conditions, but researchers said their activity failed to entirely counteract the risks that came with prolonged sitting.

Still, incorporating exercise into your day, in addition to cutting down the amount of time you spend sitting, can lower the risk for diabetes, heart disease or stroke, Barlow said. Even short, periodic bursts of activity can do the trick. And for those in need of reminders, there is an entire line of products that provide an extra nudge, tracking steps and sending alerts to get you moving.

There is even a formula to shake up your sedentary routine. Ulf Ekelund, a professor at the Norwegian School of Sports Sciences, found one hour of exercise — anything from a stroll in the park to biking to work — is a good start if you sit eight hours a day. In other words, for every four hours of sitting, you need at least 30 minutes of exercise, Ekelund said in a study released earlier this year. You don’t have to do it all at once; sprinkling some activity throughout the day is just fine, he said.

 

Douglas-Gabriel, Danielle. “More evidence that we need to stop sitting so much — especially men.The Washington Post 21 Dec. 2016.

March Feature: How new mothers can avoid injury when starting to exercise again

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“How new mothers can avoid injury when starting to exercise again”

 

One January morning, while attempting my first jog since the birth of my 6-week-old baby, I was taken aback by my low endurance as I plodded along, hyperventilating and draped over the stroller’s handle.

I soon discovered endurance was only the beginning of the physical challenges I’d experience as a new mom. Pregnancy and childbirth can also weaken abdominal muscles, loosen ligaments and cause structural changes in the rib cage and pelvis. All of this makes a woman prone to injury if she pursues a bikini body too quickly.

Pregnancy hormones stay in the body for about three months postpartum, continuing to loosen joints, muscles, tendons and ligaments as they did in preparation for delivery. For those breast-feeding, hormones can have a loosening effect even a few months after nursing stops.

Marianne Ryan, owner of Marianne Ryan Physical Therapy in Manhattan and author of “Baby Bod: Turn Flab to Fab in 12 Weeks Flat,” urges new and especially breast-feeding mothers to exercise carefully. “Don’t do too much too soon,” she says.

Jackie Zipkin, an environmental engineer from Northern California, tore her anterior cruciate ligament while playing volleyball six weeks after giving birth. “After jumping to hit the ball, I landed and felt my knee pop,” says Zipkin, who says less exercise during pregnancy and postpartum weakness contributed to her injury.

Another common postpartum problem is diastasis recti, a separation of the “six-pack,” or rectus abdominis, caused, in part, by loose connective tissue. It goes hand in hand with abdominal weakness and instability and is often associated with back pain, “mommy tummy,” urinary incontinence, pelvic organ prolapse and umbilical hernias. Ryan says up to 60 percent of new mothers have the condition, with 30 percent still affected one month postpartum.

Diastasis recti is considered, from a medical standpoint, a hernia, says Joan Loveland, a gynecologist and obstetrician in the District. Most hernias are ignored until they become symptomatic, which is one of the reasons physicians don’t check for diastasis recti in postpartum mothers. In recent years, physical therapists’ insistence that diastasis recti and pelvic floor problems are treatable has become more mainstream.

“Everything comes from the pelvis. It’s such a critical area to ensure strength and wellness and fitness,” Loveland says, describing why diastasis recti affects a woman’s well-being. “I think [physicians] always thought of it as more of a cosmetic thing.”

Yet after an obstetrician gives the green light for all activity at the six- to eight-week checkup, a woman is typically left to her own devices, whether she delivered vaginally or via C-section. As a result, a new mother may overdo it when exercising without rehabilitative guidance, or may avoid fitness altogether for fear of damage.

Women’s health experts emphasize rehabilitation before fitness.

“You can work out for an hour every day, but what you do in the remaining 23 hours adds up to more,” says Kelly Dean, a physical therapist and founder of the Tummy Team, a Washington state clinic and online program. “Birth is probably the most physically demanding thing many women are going to do, but we expect them to jump into a Zumba class right away. More is not better. Better is better.”

Here’s what specialists recommend for new mothers.

 

Rehabilitate with daily activities

Everyday movements such as picking up a baby, loading a stroller into a car and walking are opportunities to engage the core muscles, which refer collectively to multiple muscle groups including the transverse abdominis (deep corset-like muscle), six-pack, obliques, diaphragm, lower back and pelvic floor.

Ryan recommends getting up from a chair by bending forward, pressing the heels of your hands into your thighs to take the weight off the belly and exhaling. To get out of bed, roll onto your side, shoulders and hips moving together with knees bent, drop your legs down off the bed and push up with your arms. Avoid jackknife movements.

Sit on your sit bones, not your tailbone.

Says Dean: “Visualize a cable from the crown of your head drawing you up. Keep arms in line with your torso and eyes on the horizon.” This gets the spine into a neutral position with the rib cage stacked directly above the pelvis and perpendicular to the ground, and shoulder blades resting back and down.

 

Breathe

Diaphragm or “belly” breathing is another simple way to engage and strengthen the abdominals. “When you inhale, fill your rib cage up with air. When you exhale, bring your belly to the spine,” says Cheryl Bjornson, a certified personal trainer in Northern California who specializes in core and diastasis recti rehabilitation.

Ryan recommends exhaling to match the level of effort during daily tasks. “If they lift up the baby, it might be a little exhale. If they lift up a pot of pasta, it must be a big exhale.”

 

Get checked

Because physicians generally don’t check for diastasis recti, ask your doctor to do so at your postnatal appointment. If you’ve already had your postnatal checkup and are experiencing symptoms, here is an instructional video from the Tummy Team on how to do it yourself.

 

Get moving

As soon as you feel well enough to leave the house, start walking — first around the block, then slowly increasing to three to five miles daily, if possible, Bjornson says. Remember during any activity to have the spine in a neutral position, engage the core and belly, breathe.

After walking for a few weeks and feeling strong, consider addingactivities that boost the heart rate: light jogging, using the elliptical machine, strengthening/toning and group workouts with other moms. “Do these same activities for a couple of weeks, see how your tummy feels, then try something more challenging like cycling, swimming or yoga,” Bjornson says. “But don’t do it all at once. Patience is key.”

 

Ditch the crunch

Avoid movements that put pressure on the abdominals, including push-ups, mountain climbers, planks, Pilates 100s and, especially, crunches, which focus on the outer abdominals but don’t develop the entire core and can worsen the separation for women with diastasis recti. Replace burpees with squats or squat jumps. Opt for modified push-ups and planks. Instead of crunches, try heel slides, bridges and head lifts. Avoid positions where the belly is parallel to the ground until you can engage your deep corset muscle throughout the exercise, Bjornson says.

 

Don’t do it alone

More resources are becoming available to new mothers, such as physical therapists specializing in prenatal, postnatal and pelvic floor health, as well as books and online programs.

“Be vocal if you feel you have core instability and diastasis,” Bjornson says. “Don’t assume that the trainer knows more than you do. Be your own advocate.”

 

Rumer, Masha. “How new mothers can avoid injury when starting to exercise again.The Washington Post 13 December 2016.

February Feature: A personal message from Dr. Li

Posted by on 1:42 am in Tips | Comments Off on February Feature: A personal message from Dr. Li

In response to “Why Daily Weight Lifting Can Be Dangerous“:

This article reminds me a lot of the questions my patients have been asking me over the past month. As you may know, I like to recommend weight training for my patients since it’s the most researched method of changing one’s body and health. While I do like the recommendation regarding a 48-hour rest, I would like to add more to it!

Do you usually struggle to squeeze in time to do your home-care exercises? Use the exercises I have prescribed as an “active rest” in between your weight training exercises. For instance, do a set of the dead bug exercise in between your squat. By exercising this way, you get the benefit of both worlds: rehabbing your injury while also getting stronger.

Check out this video I made about getting back to exercising:

Dr. Li shares some tips to help you move better and FEEL better when working out! –#MobilityPlusSportsRehab #MoveBetter #MoveMore #MovementCulture #StrongerTogether #LetsMove #Seattle #Belltown #DowntownSeattle #SouthLakeUnion

Posted by Mobility Plus Sports Rehab on Wednesday, January 4, 2017

February Feature: Brittney’s tips to avoid over-training

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No matter what your activity is, from walking to weight lifting to synchronized swimming, there is always a risk of over-training leading to injury. Here are my top 3 tips to avoid it:

1. Strategize your week

A good rule of thumb: no more than 3 high intensity days per week, always followed by a recovery day. If you want to train more days you can decrease the intensity and train 2 days in a row.

2. Recovery > Rest

You might have noticed in point #1 that I didn’t talk about rest days but recovery days. No, Netflix and chill doesn’t count. Take advantage of these days to alleviate some of the wear and tear you put your body through. Light activity, accessory work, mobility and soft tissue work are perfect for these days.

3. Post-Workout Routine

Right after your workout there is a window of time where you can help your body recover as efficiently as possible. You do this by:

  • Getting a good meal with quality protein
  • Re-hydrating
  • Replacing electrolytes
  • Stretching (the only time static stretching is helpful)
  • Getting plenty of sleep

 

 

 

 

 

February Feature: Overuse Injuries & Weight Lifting

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“Ask Well: Why Daily Weight Lifting Can Be Dangerous”

 

Q: I have always read that in weight training, one should rest a day between workouts targeting the same muscle groups. Is there proof that targeting them on consecutive days is harmful? What about people who have some heavy lifting in their day jobs?

A: Weight training, especially if your body is not used to lifting weights, harms muscle tissue in the short term while also prompting the tissue to repair itself and become stronger, said Stuart Phillips, a professor at McMaster University in Canada who has long studied weight training. In 1997, he and colleagues published a seminal study showing that within three hours of a bout of strenuous weight training, men and women develop significant increases in markers of tissue breakdown that remain elevated for 24 hours. At the same time, their muscles begin to show rising levels of other markers related to tissue repair and growth that linger for a full 48 hours after the workout.

These findings, which have been replicated many times since, strongly indicate that muscles benefit from a day or two of rest between training, Dr. Phillips said, in order for them to complete the Nietzschean rip-and-repair cycle.

“Plus it’s not just muscle” affected by weight training, he said. “Connective tissue in joints also needs a recovery period.” In fact, joints can be more prone to injuries from daily weight training than muscles, he said.

As for people whose jobs involve frequent heavy lifting, they generally develop a tolerance to the loads that they regularly lift, he said. But even with that familiarity, they often develop overuse injuries in their backs, wrists and other joints, Dr. Phillips said.

So his advice is to wait 48 hours between sessions of strenuous weight training that target a particular muscle group. You could focus on upper-body muscles on one day and leg and lower-back muscles the next, if you enjoy visiting the gym daily. But don’t exercise all of the muscles every day. “Muscles and joints need rest to recover and regenerate,” Dr. Phillips said.

 

Reynolds, Gretchen. “Ask Well: Why Daily Weight Lifting Can Be Dangerous.The New York Times 26 Feb. 2016.

February Feature: Avoiding Overuse Injuries

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“4 Ways to Avoid Overuse Injuries This Spring”

 

Spring is here and you’re ready to really cover some miles. No more ice and snow and miserable winds to hold you back. Watch out though. All the beautiful weather in the world won’t make up for being grounded by overuse injuries. Follow these guidelines to reduce your risk of running yourself into the ground.

Maximizing running performance requires you to improve conditioning by overloading–slightly surpassing present functioning levels–both the cardiovascular and the musculoskeletal systems. However, excessive overload exceeds the body’s ability to adapt to the increased stress and overuse injury will occur. Therefore, you must be very cautious in selecting an appropriate overload, one which will provide optimal conditioning without producing injury.

Cardiovascular Vs Mulculoskeletal Conditioning

Perceived exertion (how hard the exercise session feels) is determined by the status of the cardiovascular system or how fit you are. Since the cardiovascular system improves at a faster rate than the musculoskeletal system, reliance on perceived exertion to determine your workouts can cause you to overstress the bones, joints, tendons, ligaments, and muscles. Limit your increases in both intensity and duration of your conditioning program to no more than ten percent per week. This gives the body time to adapt to the stress provided by exercise.

Hard Day, Easy Day

Maximum gains in conditioning are obtained when appropriate rest is provided along with exercise, which enables the tissues to adapt and increase in functioning. Inadequate rest increases the probability of sustaining an injury. An intense workout should be followed by a light workout the next day. During the race season, a race should be considered a hard day. Depending on the intensity and duration of the race, additional easy days may be required. Always remember that your body makes gains in strength and endurance during recovery. If you don’t provide time for recovery, the body can break down.

Recognize the Symptoms of Overuse Injuries

Overuse injuries can be prevented if you are familiar with the progression of injury, and you modify your workout prior to the onset of injury. Overuse injuries usually progress through stages, which include:

Benevolent pain is good pain that is a normal result of overload within a conditioning program. This type of pain is present after activity, but is absent by the time of the next day’s practice or is relieved by warm-up.

Semi-harmful pain indicates that you are starting to get in trouble. Semi-harmful pain is pain that is partially relieved by warm-up. It is present during activity but performance is not noticeably reduced. When semi-harmful pain is recognized, your conditioning program should be cut back and the treatment regimen described below should be followed. If the pain lasts more than one week, or is severe, get medical attention.

Harmful pain indicates that you are in trouble. With this type of pain, performance is noticeably reduced and is not relieved by rest. A period of rest and medical attention will likely be required before continuing a conditioning program.

Treatment

Overuse injuries are generally treated by RICE+AR.

Rest-Determine a level of exercise, which produces only benevolent pain, and provides relative rest. This may require complete rest from the exercise program for a few days or possibly cross training with a different sport.

Ice-Apply an ice pack several times a day for about 15 minutes at a time. This is especially important during the first 24 to 48 hours after injury.

Compression-Apply an elastic wrap with comfortably firm pressure during and after ice application. Remove the wrap during sleep.

Elevation-Elevate the injured area above the level of the heart whenever possible.

Anti-inflammatory medication such as aspirin or ibuprofen can be used to assist in the reduction of the inflammation.

Re-condition with stretching and a gradual progression to strength training and gradual return to running. If improvement is not felt in three to five days, seek medical attention to get going with a specific treatment program so that you can return to running injury-free.

 

Peppard, Alan. “4 Ways to Avoid Overuse Injuries This Spring.Active.com.

February Feature: Overuse Injuries & Specialization

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“Overuse Injuries: New Evidence, Prevention and Treatment”

 

New evidence shows a direct link between sport specialization and overuse injuries.

 

During the winter, a teenage girl visited my office. For the third time in a few years, she had injured her right wrist. Each of these injuries was due to the hours of practice and competition the gymnast logs weekly. She rarely takes days off.

This girl is hardly alone. Thousands of kids nationally are diagnosed with overuse injuries every year, as young body parts and minds succumb to sport specialization and year-round play. Overuse has afflicted young athletes throughout my 18 years of practicing pediatric medicine, but it has become especially prevalent over the last decade.

New evidence, however, shows a direct link between sport specialization and overuse injuries, and other new research diminishes specialization’s role in breeding elite athletes. In short, we now know that specializing not only does not help preadolescents become elite athletes, it also harms them physically and emotionally.

While advocates work on changing the pressurized amateur sports culture, parents and coaches can address overuse more immediately. Research has illuminated preventative methods and treatments are simple to follow – if not what some parents and athletes want to hear.

The Ramifications of Specializing

Injuries such as stress fractures, jumper’s knee and Osgood-Schlatter’s disease occur when muscles, bones and ligaments are worked beyond their capacity. Young athletes also suffer from emotional overuse, or burnout.

Kids are more susceptible to overuse than adults because their bodies and minds are not as developed. Their ligaments are not as flexible, leading to more stretching and tearing injuries. Adolescents are especially susceptible because they are growing rapidly: An adolescent’s knee is more prone to inflammation, for example, due to repetitive stress on the joint from running and jumping sports. Unrefined techniques – such as incorrect form on tennis serves or swim strokes – also lead to injury when combined with overuse, as does poorly fitting athletic equipment. Psychologically, kids are more likely to grow tired of doing the same thing, such as free throw shooting or fielding drills, or even playing in competitive games.

Combine this internal makeup with pressure to earn a starting spot on a team or a college scholarship, or to be there for the team – pressure that drives kids (and their parents) to ignore pain and medical advice.

Then it’s no wonder that overuse injuries have accelerated. They accounted for about half of visits by patients ages 5 to 17 to a sports clinic over a 10-year study, and two-thirds of the 846 injuries sustained by kids ages 7 to 18 who were studied over three years at two other sports clinics. These figures are probably lower than real trends because kids often don’t report overuse injuries.

Where and when do overuse injuries occur? They strike in the lower leg, knee and shoulder most often, although boys also sustain many in their lower back and feet. They are most likely to occur in girls’ and boys’ track and field, plus girls’ field hockey, lacrosse and gymnastics. Girls are more susceptible because they typically enter adolescence earlier, and their wider hips put more stress on their knees.

Both girls and boys are hurt by playing only one sport and doing it year-round, which are the chief catalysts for the dozen overuse injuries I see almost every week. But we may soon reach a turning point. Research published within the last two years disproves a theory held by many sports parents and coaches: (More) practice makes perfect.

Researchers have found that sport specialization:

  • Leads directly to overuse injuries, with risk increasing in proportion with degree of specialization.
  • Does not help preadolescents become elite athletes because overuse or burnout often trips them up.
  • Stifles motor skill development in preadolescents, increasing future injury risk.

Researchers have also found that unstructured activities and playing multiple sports before adolescence best predict long-term athletic success and psychological maturity. The American Academy of Pediatrics and American Medical Society for Sports Medicine now recommend against early sport specialization for preadolescents and early adolescents.

Preventing Overuse Injuries

Armed with this new evidence, parents, coaches and trainers can help prevent overuse injuries. First, encourage younger kids to sample different sports and activities, and don’t allow them to play any sport year-round. Second, make sure they get rest from structured activities at least once a week, and at least two months’ rest between seasons. They should also get plenty of calcium in their diet to stimulate bone growth, and do stretching exercises to make their ligaments and tendons more flexible.
Adolescents, and younger athletes in “early entry” sports such as swimming and tennis, may specialize if they want to, but watch for signs of burnout and see their regular doctor if they complain of pain. Also ask a qualified trainer to direct integrative training for them, to develop more diverse motor skills and reduce injury risk.

All kids should listen to their bodies. If they feel pain, they should take time off.

Treatment and Recovery

If kids suffer overuse injuries, most recommended treatments are fast-acting and low-risk over the long term. More than 8 in 10 adolescents treated for spondylolysis in one study had a successful outcome after at least one year, for example, and four-fifths of the 3,147 high school athletes who sustained overuse injuries in another study returned to action within three weeks.

When young athletes complain of pain, they should see their regular doctor. Most kids will only need a simple exam, not X-rays or a consultation with a specialist.

If the doctor diagnoses an overuse injury, treat it by applying ice for 24 hours, followed by heat. Administer anti-inflammatories, consider braces for ankles or knees, and ask a trainer to recommend proper stretching and muscle-strengthening exercises. Most importantly, make sure kids rest for at least 7 to 10 days. That means no games, no practice, no training. Just rest. If it still hurts when kids return to action, rest some more.

I know it’s not easy for parents and kids to take that advice. When I diagnosed an elbow injury in a teenage boy last spring, his father told me resting “is not an option.” The boy was pitching on two baseball teams and did not want to miss any of the season. But if he returned to action too soon, he risked suffering a much more debilitating injury that could have sidelined him for several months. The same risk goes for any overuse victim who does not get proper rest.

I understand parents don’t want to hear that warning either. They fear alienating their kid from teammates and coaches by holding the kid out. But it’s the parents’ responsibility to say, “This is enough.” You have to stick up for your kid, who is still a minor no matter how physically gifted or dedicated.

A Call to Action

The gymnast I saw is very gifted and dedicated, practicing six days each week and competing once each month. Her mother knew she could not keep up that pace. “But the coach won’t let me quit,” the girl said. She was too emotionally invested and feared letting her coach and teammates down. When I asked her to rest for 10 days, she sat for two.

I expect to see her again. But you can avoid extra trips to the doctor – or worse. Take overuse seriously. Now that we know how much it harms kids, it’s tough to justify pushing them so hard in sports – even if they want to be pushed.

 

Thibodeaux, Brent. “Overuse Injuries: New Evidence, Prevention and Treatment.U.S. News 20 April 2016.

February Feature: Overuse Injuries & Hip Pain

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“As millennials flock to high-intensity workouts, hip pain follows”


Physical therapist Karena Wu couldn’t help notice a trend in patients visiting her New York City office this year. Many were under age 35, enjoyed strenuous workouts and were suffering immense hip pain.

The millennials had pushed themselves in endurance races such as the Tough Mudder or weekly CrossFit and metabolic conditioning classes that placed wear and tear on their bodies, she said. And with little downtime between routines or adherence to proper form, they were putting the long-term health of their hips at risk.

“A lot of millennials are doing all of these high-intensity exercises that are great for the mental and physical components of health, but if you’re not as conditioned as you think, you’re going to put excessive stress on the soft tissue and the joint,” said Wu, owner of ActiveCare Physical Therapy.

It’s not uncommon for active young adults to experience some joint pain, but orthopedic specialists worry that regimens that rely on heavy weightlifting or intense aerobic exercises are causing more hip injuries. There are no definitive studies that correlate the two, but research in the Journal of Orthopaedic & Sports Physical Therapy says high-intensity activities appear to increase the risk of hip osteoarthritis, a degenerative joint disease.

What’s more, specialists at the Ohio State University Wexner Medical Center have reported a rise in cases of young adults with femoral acetabular impingement, a condition that occurs when the ball of the femur fails to fit securely into the hip socket. High levels of activity, they say, can cause the plate to fuse in an abnormal shape and result in a hip impingement.

Shane Nho, an orthopedic surgeon at Rush University Medical Center in Chicago, recalls a spike in hip, shoulder and knee injuries as CrossFit gyms sprung up several years ago. These days, he said, patients are coming in with hip ailments from high-intensity interval training, even some barre classes.

“We probably see at least a couple patients a week with injuries related to those types of intensive classes,” Nho said. “The types of workouts these guys are doing . . . they’re doing it at all costs, despite poor form, mechanics, fatigue or their actual baseline level of conditioning.”

Neuromuscular imbalances, or weakness in certain muscle groups, are often the root cause of the pain that Nho’s patients experience, he said. If patients come in as soon as they start feeling discomfort, he said, it’s easier to connect them with the right physical therapist to improve their stability and flexibility.

Hips are built to withstand tremendous force, but they need full range of motion to work properly, hence the importance of flexibility and stability, Wu said. She encourages her clients to do yoga or attend a Pilates class if they are dead set on physically taxing workouts.

“Flexibility is critical in trying to prevent injuries,” she said. “The body has a tendency to overemphasize larger muscles because they are easier to activate, so sometimes they get a little overused and smaller stabilizing muscles get underused. You create an imbalance.”

A weight-room regular since high school, Niranjan Nagwekar, 28, figured there was no need to spend much time warming up before squatting 250 pounds. But as the New Yorker ramped up his lifting, he started feeling a deep pain in his left hip.

“For the longest time, I thought I just had tight hip flexors, so I started stretching a little more, but the pain persisted,” Nagwekar said. “I didn’t feel much discomfort walking or sitting down, so it was kind of a strange thing to explain to a doctor because they were like, ‘If you could walk, you could sit, you’re fine.’ But I couldn’t lift as much as normal.”

It turns out Nagwekar had developed a hip impingement. Doctors recommended surgery, but he decided to opt for physical therapy.

Nagwekar became a patient five months ago at ActiveCare, where Wu has guided him through mobility exercises involving foam rolling, core conditioning and stretching with resistance bands.

“I’m back to about 80 percent capacity,” Nagwekar said. “Any kind of power lifting that requires dynamic movement of the hips takes me a little longer. My hips don’t move as fluidly as before, but I can still do them.”

 

Douglas-Gabriel, Danielle. “As millennials flock to high-intensity workouts, hip pain follows.The Washington Post 21 Dec. 2016.

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