Monday, December 28, 2015

Are You Looking At Everything? It May Be A Good Idea.

While the phrase "paralysis by analysis" is a concern, often, in healthcare, the opposite can be true. It is not uncommon to experience segmentalized medicine when seeking treatment options for an ailment. With the current state of our healthcare system, doctors are stretched thin. With increased documentation demands, never ending code changes, insurance regulation compliance, decreasing reimbursement, increasing overhead costs, etc., doctors are typically unable to practice using the same model today as even ten years ago. By default, these changes are promoting a segmentalized treatment model. Doctors, by and large, are not thrilled about this emerging reality. But in order to continue helping their patients, doctors are required to adapt their approach. Additionally, training methods have changed. As more discoveries have been made, fields have become quite complex. It is impossible to know everything about everything, so specialists are required to focus on segments of the patient. Many other factors are at play, but suffice it to say that treatment approaches have largely become segmentalized. So how does this effect the patient? In some ways, it means more directed care for a simple or emergent condition. If the patient is feeling chest pain, left arm numbness and/or tingling that radiates into the jaw and other cardiac health signs/symptoms, having segmentalized processes helps expedite the life-saving measures that can save this patient's life. But this model does not work as well for other types of conditions, such as non-specific low back pain. If we approach this condition the same way we approached the earlier symptoms, the results may not be as positive. What happens when a person sees their doctor with low back pain? The typical response from the medical model is an anti-inflammatory, pain medication, and/or a muscle relaxer. Maybe that is the best course of action in this case (certainly I have been told by patients that this approach fixed their back complaints and I am thrilled for that), but maybe it is not. The typical response from the chiropractic model is an adjustment. Will that help? Maybe, maybe not. Most of the time it is hit or miss because the underlying cause of the pain can be difficult to assess during a short examination. And remember, it has already been established that the current system does not lend itself to long, time-consuming examinations. In this case, what is a patient to do? Below are a few helpful tips to help a patient receive the diagnosis and treatment that is best for them.
1) Educate yourself. In this day and age, information is readily available. Know how to describe what you are experiencing, i.e. the pain is sharp, dull, radiating, vague, pin-point, constant, intermittent, worse with activity, no change with activity, worse at night, better/worse with sitting, etc. All of these descriptions mean something and will help in the diagnosis. Look for an internet forum or a few friends/family who may be able to help you identify and describe your symptoms. Being able to elaborate on your symptoms can be of great benefit when describing the condition to your doctor.
2) Remember that your doctor is pressed for time. It is not that your doctor does not care (usually). The reason they do not spend much time with you is because they are trapped in the system described in the opening of this article. Truthfully, they do not like only having a few minutes to spend with you, either. Your doctor did not go into healthcare to ignore you. They went into the field to help people (usually), so make it easier for them to help you in the limited time that they have. Be prepared with a list of questions, an accurate description of your concerns (detailed above), and a little understanding of what the doctor is trying to do for you.
3) Ensure that you are in the correct office. Are you seeing the correct doctor for your condition? You likely would not see a cardiologist for a sprained ankle, so make sure you are seeing the correct provider for the condition. This is another instance where being part of a network of people who have experienced similar symptoms can be helpful (such as an internet forum, etc.) because they may be able to help you decide on a good first step.
4) Have the doctor explain what you can expect. One important aspect to treatment and healing is having a plan. This plan should be fairly direct, but allow for unforeseen circumstances as well. As much as can be expected, try to have an understanding of the course of treatment and what you may be able to do on your own to achieve the overall goal.
5) Seek a provider who will listen to your concerns and approach your condition individually. Not every condition is the same. Similar complaints can require very different treatment approaches (i.e. 'shoulder pain' may require mobility work due to adhesive capsulitis or it may require intrinsic stability work due to a torn labrum. Both of these conditions will produce 'shoulder pain', but if the treatments are reversed, both of these patients could end up in surgery to repair a condition that may have otherwise been managed conservatively. The provider's initial attention to detail is an important factor in creating the proper treatment direction.
There are many other ways to ensure that your treatment(s) are properly devised and managed, but hopefully this discussion gives the patient a few ideas on how to better prepare for a visit and ways to improve the chances of a positive treatment outcome.
All the best,

Nathan Williams, DC, MS

Sunday, April 14, 2013

Fatigue Leads To Poor Form (which leads to injury)

This is an issue that is becoming more common with today's workouts. The idea of pushing one's body to fatigue is a common idea in recent exercise programs. With fatigue comes some wonderful physiological advantages such as an increase in muscle gain, a decrease in blood sugar levels, slower fatigue during sporting endeavors, a quicker response to anaerobic activity, etc. However, we have seen a dramatic increase in injuries resulting from workouts where participants are pushing into (and past) fatigue. These injuries range from simple strain/sprains to serious injuries such as labrum tears, stress fractures, muscle tears, severe tendinitis, and enthesopathies (a disruption of the junction between a muscle and bone). The cause of these injuries can be traced back, in many cases, to poor form. As the participant fatigues, intrinsic muscles that are designed to protect joints become compromised. If intrinsic muscles become fatigued, proper form is impossible to maintain. When this occurs, the joints become vulnerable by absorbing stress loads that they are ill-equipped to manage. It is at this point that injury becomes possible because the muscles are unable to protect the joints. So, the take-away from this discussion should be the maintenance of proper form during lifting, no matter the program. In my office, I do not discourage the athlete from pushing themselves to fatigue. As mentioned above, there are many benefits to reaching fatigue during exercise. However, I am adamant that my patients maintain proper form at all times. Fatigue is reached when the athlete can no longer perform the particular exercise with proper form. At this point, the athlete is encouraged to cease that particular movement and any others that rely on the same intrinsic stabilizers. An example would be that if an athlete reaches fatigue after performing squats, dead lifts and cleans/snatches should be avoided for the rest of that particular workout. If there are any questions, concerns, or comments about this idea, please relay them. All the best, Nathan Williams, DC, MS, TPI-med3

Tuesday, July 10, 2012

How Do You Roll?

Chronic low back pain is common in our society. As we age, the rate of incidence regarding chronic spinal pain, particularly the lumbar spine, increases. Mobility, stability and flexibility are often decreased in this population of pain sufferers. Interestingly, as these markers (mobility, stability, and flexibility) decrease, pain tends to increase in an inverse relationship. In these patients, it can be difficult to know there is a problem until pain arises. It is common to believe that the problem recently began since the pain recently began. However, there may have been a problem brewing for a long time, maybe for years, before the sensation of pain. There is a great way to gauge how all three of these markers are functioning that can be used in the office or at home: rolling patterns. Here is a great article by Gray Cook, PT and Michael Voight, DPT regarding rolling patterns Rolling Patterns - PubMed. In simple terms, rolling over correctly requires proper function of muscles and joints in a coordinated fashion. It seems easy, but if there are inadequacies in a patient's mobility, stability, and/or flexibility in several key regions of the body, the movement's difficulty may be surprising.

Try the rolling pattern laying on your back and rolling to your stomach using only your arms and upper body. Then reverse onto your back using only your arms and upper body. Then try it with only your legs and lower body. You may find that some movements are easier than others. If so, this may be an underlying contributor to spinal pain. If you do not currently have spinal pain, this movement pattern may be a predictor of future problems. Try this movement and report the results to your movement specialist.

Tuesday, June 28, 2011

Asymmetries: What's the Problem?

Asymmetries are some of the biggest predictors of injury in our population, especially in athletes. By 'asymmetries', I am referring to joints and/or muscles that perform differently from one side to the other.

Example: A sprinter with 20 degrees of hip extension in the left hip and 35 degrees of hip extension in the right hip is at risk of injury. Why? When a sprinter is at full stride, hip extension is utilized in the trailing leg. If, with every stride, the difference between the left and right hip motion is 15 degrees, the pelvis, hips, and lumbar spine (at the very least) will absorb that difference in the form of strain. When the tissue threshold is met, the sprinter will develop pain.

Now comes the interesting part. Most health care practitioners are trained to treat the sprinter's pain. As such, this athlete will receive stretches, strengthening exercises, therapies to decrease the pain, manipulations, and possibly medication or surgery. But what if there were a system designed that could have caught this injury before it ever happened? Well, there is. Check out the following website: If you are an athlete or health care professional and do not know Gray Cook, you should change that. Asymmetries have been shown to be reliable predictors of injury. In the example above, it would be better for the sprinter to have 20 degrees of hip extension bilaterally than to have asymmetrical findings. In the coming years, I 'predict' (speaking of predictions) that Cook's FMS (Functional Movement Screen) system will continue to gain popularity in athletes as well as non-athletes. With strong predictors of injury, such as asymmetries, within the system, our patients and clients can not afford for us to under-utilize the FMS.

Saturday, May 21, 2011

Hip Pain: Does it mean I have a problem with my hip?

The answer is, of course, not necessarily. Pain can arise from many tissues: muscles, tendons, ligaments, joint capsules, bones, nerves, etc. While certainly all of these components collectively comprise the hip (and can cause a great number of conditions that lead to hip pain), hip pain does not necessarily arise from the hip itself. Referred pain patterns are not uncommon and should be considered when diagnosing hip pain. This becomes a very important distinction when working with golfers. Hip pain can develop as a result of so many different problems. It matters where the pain is located (front, back, side, combination, etc.) and what type of pain is being described (sharp, shooting, dull, achy, burning, etc.). The golf swing can cause the pain or it may not. Is the pain arising from the hip or from somewhere else that causes the hip to hurt? As a golfer, it is important to be evaluated by a doctor who is familiar with the golf swing and the biomechanics involved in the movement.

Recently, I saw a patient (an avid golfer) in the office who was experiencing hip pain that had been getting worse. The patient had received a full work-up on the hip from another provider and had undergone therapy for pain. Despite extensive efforts, the pain was becoming worse. When the patient presented in my office, I did the most obvious thing to do: I examined the painful hip. But after the evaluation, it was evident to me that the hip was not the generator of the pain. So I looked at the next most likely cause of hip pain (outside of the hip itself) and uncovered the culprit. It originated in the lumbar spine; L4/5 to be exact, and our findings were confirmed by MRI.

The important take-away here is that referred pain can be tricky to diagnose. If you are experiencing pain that has not been managed to your satisfaction, it can be worth your time and effort to seek out a second opinion. And when looking for a second opinion, look for a doctor that is knowledgeable about the golf swing. It can make all the difference in receiving the proper diagnosis and treatment plan.

All the best,

Nathan Williams, DC, MS, TPI-CGFI

Tuesday, April 5, 2011

Tennis Elbow In The Golfer (confusing, I know)

Tennis Elbow seems to be the injury of choice for golfers in our clinic lately. Don't let the name fool you - a golfer can certainly develop Tennis Elbow. Actually, Tennis Elbow seems to be more common in golfers than tennis players! This condition can make it difficult to swing a club comfortably and, in some cases, force the player to sit out of the game altogether. With the golf season in full-swing (pardon the pun), neither of these options is appealing to most players. So, let's talk about what Tennis Elbow is and how you can prevent it from hindering you this season.

The Mayo Clinic defines Tennis Elbow as a painful condition that occurs when tendons in your elbow are overworked, usually by repetitive motions of the wrist and arm. This is mostly true. But overuse is not the only culprit; misuse is just as troublesome. The pain that you feel on the outside of the elbow is coming from the tendons that attach to the bones. These tendons are also attached to the muscles that make your wrist extend, or bend up. This is important because it is this motion that can cause the condition. It is most common to see Tennis Elbow in the left arm of a right-handed golfer. Also, these players typically complain that they have lost distance, have begun to slice the ball, catch the ball "fat", and/or hit high, weak shots that tend to go to the right. There is one major move that golfers make that can lead to these problems:

Can you see the problem? It is called "scooping the club" and it can lead to all of the shot pattern problems described earlier as well as Tennis Elbow. This move puts a large amount of stress on the muscles that extend the left wrist. When the problem occurs in the left elbow of a right-handed player, it is typically an injury of misuse, not necessarily overuse.

The solution? Stop scooping! Ok, I understand that this is far easier said than done. But in order to prevent the recurrence of pain, it is a must-do. Check with your local golf instructor for drills and swing keys that allow the hands to be ahead of the clubhead at impact. This will reduce the amount of load that is placed on the elbow muscles (and vastly improve shot results at the same time). But what if a player currently has Tennis Elbow? Is there anything that they can do now to improve their condition until the swing change takes place? Yes! The following are good tips to decrease the pain associated with Tennis Elbow:

1) Use ice, NOT heat. Some patients believe heat is the best option for all muscle pain. Au, contraire. A good rule of thumb is if the condition is painful, use ice. If pain is present, then inflammation is not far behind. Heat increases inflammation leading to more pain about two hours after the application of heat. Heat feels good while it is being applied, but leads to more pain afterwards. Ice should be applied for 10-15 minutes and then removed for 45-50 minutes. This cycle can be repeated three times in the morning and three times at night. (Disclaimer: Do not apply ice for more than the prescribed time. It can burn you just like heat).

2) Use a wrist-rest at the keyboard. Once pain is present in the elbow, it does not take much to produce more pain. Typing at a keyboard can force a person to overuse the wrist extensors.

3) Compression bands can help, but should only be used as a temporary solution. Eventually the goal is to address the culprit of the pain and alleviate it permanently. But until that can happen, a compression band can provide some relief to the elbow.

4) Avoid tons of full-swing shots. Use this opportunity to polish up on your short game instead of pounding 200 balls as hard as you can on the driving range. You can still play, just don't over-do it.

5) Avoid sleeping with your arms above shoulder level. We spend as much as 33% of our lives sleeping. It is important to ensure that your sleep position is conducive to the health of your body. Some elbow pain has been linked to sleeping with arms overhead.

If you have any questions, please contact us at Germantown Golf Fitness in Germantown, TN. Our phone number is (901) 590-1065.

All the best,

Nathan Williams, DC, MS, CGFI-MP2

Tuesday, March 8, 2011

Importance of Rotation in the Golf Swing

Over the past couple of years, a lot has been said about recent changes in golf instruction. Sean Foley and the Stack and Tilt guys (Andy Plummer and Mike Bennett), among others, are sources of constant discussion due to their seemingly "new" way to swing a golf club (a closer look at traditional swings, however, will reveal that the swing as it has been taught over the last couple of decades is actually the "new" one). I will also say from the outset that I do not promote S&T, but some of their principles are fitting for this article. Sean Foley's approach to the golf swing, on the other hand, seems to be directly in line with my approach. Although the teachings of S&T and Foley are absolutely NOT the same, an area of commonality is the importance that is placed on rotation in the swing. And therein lies the problem. For years we have been taught to "load the right side" during the back swing, and to "shift our weight" to the right at the top of our swing in an attempt to create more power. Some of the greatest swing instructors of our generation have promoted this technique. In David Leadbetter's 2004 book Unlocking Your True Golf Potential, he writes "Sense that your weight is shifting onto your right side as you turn against that braced right knee and thigh" (referring to the back swing). However, research would disagree with this popular method. Loading the right side is an ineffective way to generate and release energy, and it opens the player up to other problems. It is my opinion that this movement pattern leads to inconsistent shot patterns, a loss of distance, and potential injuries. The following is the scientific reasoning for these thoughts:

In physics, Newtonian force is defined as an influence on a body, producing a change in movement (1). This definition applies to Newton's first law that Every material body remains in its state of rest or uniform, unaccelerated motion in a straight line, if and only if it is not acted upon by a net force (2). The problem with this approach is that this describes linear dynamics only. There are many forces, in many vector directions, being applied to a golfer's body and club during the golf swing. Each of these vectors play a role in the net force being translated into the golf ball. The golf swing is comprised of rotational dynamics, which include additional complicating factors. When rotation is added, torque is introduced. Newton's second law states that a body of mass subject to a net force undergoes an acceleration that has the same direction as the force and a magnitude that is directly proportional to the force and inversely proportional to the mass, i.e., F = ma. Torque, by definition, is the tendency of a force to cause or change rotational motion of a body. Torque depends on the magnitude of the force and on where the force is applied relative to the pivot point. Hence, the rotation axis's location greatly affects the torque produced (3).

So, all of that to say this: If the golfer's muscles are the generator of force and the spine is the axis of rotation, it is counter-productive for the generated force to be moved from the axis's original location. No added power is produced by "loading the right side" because the axis of rotation is deviated causing a loss of rotational muscle tension and decreasing the player's ability to transition to the left in the downswing. This difficulty in transitioning to the left on the downswing has caused the most common "miss" among amateurs to become a slice over the past couple of decades. In years prior, the most common "miss" was a hook. In the professional golfer, the most common "miss" has become a block to the right. This is because the player's timing must be perfect in order to return the club back to the ball consistently. If that timing is interrupted, compensations ensue that cause a plethora of problems (i.e. flipping the hands through impact, over-the-top swing planes, hanging-back through impact, sliding, swaying, etc.).

Also, the injuries that result from this movement are usually seen in the right-sided low back, left hip, left knee, and left shoulder. That is because these areas take high amounts of stress during the swing when the player "loads the right side". Stress on these areas can be decreased if the center of mass is not moved from its original position during the back swing.

Baseball pitchers have figured out this concept. How long will it be before more golf instructors figure it out too?

(notice the amount of "loading the right side" during the wind-up in earlier pitching forms)

(notice pitchers now maintain centered weight distribution during the wind-up, relying on rotation and forward motion to generate power and consistency)

All the best,

Nathan Williams, DC, MS, CGFI-MP2

1. Physics, the Human Adventure: from Copernicus to Einstein and Beyond; Holton, G., Brush, S.; 2005; p. 108

2. Physics, the Human Adventure: from Copernicus to Einstein and Beyond; Holton, G., Brush, S.; 2005; p. 108

3. College Physics: Reasoning and Relationships; Giordano, N.; 2009; p. 249