Health & Fitness News: Pain Science, Breakfast – To Skip or Not to Skip?, Carbs vs fat (Whither protein?), 8 Glasses of Water Mythology

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Several articles have grabbed my attention. One is a concise summary of the current understanding of pain. Another discusses breakfast and the flimsy evidence supporting its importance. Next, science looks at the efficacy of reducing carbs vs fats for weight loss. Finally, drinking eight glasses of water a day is based on nothing.

Pain and lifting

The issue of pain is a continual theme in this blog. I’ve dealt with periodic bouts of lingering pain. The upside to this is that I’ve learned a lot about pain. Whether we’re an athlete or not, most of us will encounter non-acute or chronic pain.

It can be scary and depressing to us especially if it limits our ability to train. Interestingly, learning about how pain works can actually help us feel better (low-back pain in this case). Pain is NOT simply an indication of tissue damage. It’s very much a product of the brain. How we perceive our bodies (damaged or strong), our pain (threatening and scary or just a nuisance) and our expectations (“I’m broken and ruined,” or “I’ll be fine.”) are major influences on the pain process.

In that direction, Elitefts.com has a worthwhile article called 3 Things Lifters and Coaches Need to Know About Pain. It’s concise and fairly easy to understand for non-scientists. I think this information is useful for coaches and trainers who will certainly come across an athlete or client in pain. It may also prove helpful to you if you’re in pain. Here is a summary:

1. You are not your MRI or your X-Ray. Many people have tissue damage or degeneration on imaging but walk around without pain everyday. If you’re dealing with pain or an injury, get a thorough medical history and functional examination done by a qualified health professional, preferably one that works with athletes and lifters (they are out there).

2. Understand that pain (particularly chronic pain) isn’t purely related to biomechanics or injury. Biological and psychosocial factors both contribute to a person’s pain experience.

3. When working with clients, don’t create fear or a nocebo effect by berating your clients on their lifting technique, posture, or movement capabilities. Instead, work through your client’s issues with positive coaching and cueing to build a great training effect.

Read the article to get more detail.

Breakfast and weight loss

“Breakfast is the most important meal of the day.”

You’ve heard it. You believe. I’ve preached it to clients. It seems the earth rotates around this statement. But, is this bit of gospel based on anything of substance? Not really.

In The science of skipping breakfast: How government nutritionists may have gotten it wrong the Washington Post discusses research that shows the following:

“In overweight individuals, skipping breakfast daily for 4 weeks leads to a reduction in body weight,” the researchers from Columbia University concluded in a paper published last year.”

Another golden idol knocked from its pedestal! How can this be? Why would the USDA Dietary Guidelines for Americans tell us something that isn’t supported by good evidence?

The Post article does a good job of discussing the answer.

One of the key pieces of evidence, for example, examined the records for 20,000 male health professionals. Researchers followed the group for 10 years and published results in 2007 in the journal Obesity. They showed that after adjusting for age and other factors, the men who ate breakfast were 13 percent less likely to have had a significant weight gain.

“Our study suggests that the consumption of breakfast may modestly lower the risk of weight gain in middle-aged and older men,” the researchers said.

The advisory committee cited this and similar research, known as “observational studies,” in support of the notion that skipping breakfast might cause weight gain. In “observational studies,” subjects are merely observed, not assigned randomly to “treatment” and “control” groups as in a traditional experiment.

Observational studies in nutrition are generally cheaper and easier to conduct. But they can suffer from weaknesses that can lead scientists astray.

One of the primary troubles in observational studies is what scientists refer to as “confounders” — basically, unaccounted factors that can lead researchers to make mistaken assumptions about causes. For example, suppose breakfast skippers have a personality trait that makes them more likely to gain weight than breakfast eaters. If that’s the case, it may look as if skipping breakfast causes weight gain even though the cause is the personality trait.

It’s a reminder of the very important rule: Correlation doesn’t equal causation. Just because one detail appears alongside another detail, it doesn’t mean the one detail causes the other. (Tall people play basketball. Therefore one might conclude that playing basketball makes people tall. Is that right?)

Similarly we’ve seen a recent revision on dietary fat and cholesterol guidelines. We once thought that fat (particularly saturated fat) and cholesterol were the most evil of edible substances. Based upon flawed science, we were told to replace fat with carbohydrates and we’d all be well. Upon further review, it seems we may have been very wrong.

Low-carb vs. low-fat

Sticking with the diet and science theme, there’s been a lot of discussion on a recent study in Cell Metabolism that looks at low-carb vs. low-fat diets. This was a six-day study in a carefully controlled lab environment. The study had the same group of 19 obese participants spend six days on either a restricted-carb or restricted-fat diet. They then went home for several weeks for a “wash-out” period where they resumed their normal eating habits. The participants then returned and they were switched to the other diet. The same number of calories were cut from both diets, the difference being the calories came specifically from either carbs or fat. The participants were observed in a metabolic chamber and their caloric expenditure was very closely monitored. It was a well-designed study.

The result? The low-fat group lost more fat. Discussion over right? If you saw most of the popular-press headlines you’d think so. But there’s more to the story.

First question in my mind is “What about protein?” Though the jury is still out on some aspects of high-protein diets, several studies (here, here, here and here among others) suggest that high-protein diets can be useful for weight loss. The study doesn’t mention protein at all. Seems odd to me in that carbs, fat and protein are the main macronutrients in food. Why would we want to manipulate and study the effects of just two?

A good discussion of the low-carbs vs. low-fat study can be found at Examine.com. Really-low-fat vs somewhat-lower-carb – a nuanced analysis goes into some of the limitations of the study. This article is quite detailed. Read it all if you’re up for it. I won’t go into all of it but here’s a little bit.

One point to remember that this low-carb diet could be called a “lower-“carb diet in that some low-carb diets go much lower than this one. The Examine.com article says:

“The carb levels ended up being 352 grams for Restricted Fat versus 140 for Restricted Carb, and the fat levels 17 versus 108. In other words, (moderately lower carb than typical diets) versus (oh my goodness I can count my fat gram intake on my fingers and toes!).

This trial wasn’t designed to explore a real-life 100-gram-and-under low carb diet and especially not a ketogenic diet. Rather, it was a mechanistic study designed so that they could reduce energy substantially and equally from fat or carbs, but without changing more than one macronutrient. If they lowered carbs much more in the Restricted Carb group (like under 100 grams), they’d then have to go into negative fat intake for the Restricted Fat group. And negative fat intake is impossible (*except for in quantum parallel universes). One more note: all participants kept dietary protein constant and exercised on a treadmill for an hour a day.”

So it’s possible that if carbs were lowered further, we might see a different outcome of the study. Also, this was a six-day study. We must wonder what might happen over the course of six weeks, six months or six years.

Another very important point to remember is that this was a very tightly controlled experiment. It didn’t reflect the real world in which people trying to lose weight have to make their own food choices. Examine.com says:

And to repeat a very important point: this study was not meant to inform long-run dietary choices. In the long-run, the choice between restricting fat or restricting carbs to achieve a caloric deficit may come down to one thing: diet adherence.

While preference for certain foods may dictate which diet is easier to adhere to, this isn’t always the case. For instance, it seems that insulin-resistant individuals have an easier time adhering to a low-carbohydrate diet. Nowadays, new dieters often pair low-carb with higher protein, the latter of which can boost weight loss. And since there are plenty of high-sugar but low-fat junk foods (see Mike and Ike, et al.) but not so many high-fat but low-carb junk foods, low carb intakes can sometimes mean an easier time staying away from junk food when compared to low fat diets.

So we should remember that the dietary rubber meets the road when someone seeking weight loss can modify their diet in any healthy way and then stick to it for the long haul. If it’s less fat then great. If it’s fewer carbs, also great. If it’s some other improvement to the diet then wonderful!

Eight glasses of water a day is arbitrary

Another sacred cow of health and longevity is the admonition to drink at least eight glasses of water a day. That bunk has been debunked but much like a bell that’s been rung, it’s hard to change people’s minds once they’ve heard this information. The New York Times gets into this topic in No,You Do Not Have to Drink 8 Glasses of Water a Day. This one is simple. If you’re thirsty then drink. If you’re not then don’t. (How else would we have made it to the year 2015 if we didn’t have some sort of very good water gauge built into our physiology? Do my cat or dog think about the measured quantity of the water they drink?)

My Chronic Injury is an Addict

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I'm getting off the wheel.

I’m getting off the wheel.

I’ve had recent discussions with two clients about lingering injuries. The talks brought to mind how my approach to my Achilles tendon pain. I think this new mindset will prove essential to my staying healthy and avoiding future Achilles problems. Maybe it’ll be useful to you.

To be clear, I don’t currently have any Achilles pain. I’m able to run long, sprint, and trail run consistently with no trouble. I want to keep it that way for the rest of eternity and that’s what brought up these thoughts.

Both my clients and I have battled aches and pains in particular regions that have come and gone… and come and gone again over the course of time. Our shared narratives go something like this:

I have pain. I see a physical therapist or chiropractor. He/She prescribes exercises that help. They help. I quit doing said exercises. (Those exercises are BORING as hell. They don’t feel like exercise. They don’t feel like they’re making me stronger, leaner, or more powerful.) Pain comes back at some point. Repeat the process.

Does this chain of events sound familiar?

My aches and pains have caused me to miss training, miss races and forced me out of some of the activities that I enjoy with passion. I’d like to avoid this process, thus I need to do something different from how I’ve done things in the past, otherwise I can expect the same result as before. (We all know about the definition of insanity right?)

I’ve decided that my Achilles tendon is… well… my Achilles heel. It’s my weak spot. For whatever reason, this part of my body is susceptible to problems. Therefore it needs special consideration and care. I’m now motivated to continually do the things that seem to strengthen my Achilles tendon. I want to turn that weak spot into a bulletproof, iron-clad appendage that’s nearly indestructible.

That means almost every day I’m doing standing heel raises. Some days I do high-reps/low-weight. Other days it’s heavy-weight/low-reps. I do bent-knee heel raises and straight-knee heel raises. I do heel raises with a straight foot and with my foot turned in and out. Some days I do lots of heel raises. Some days I do fewer.

My point has less to do with heel raises to cure Achilles problems and more with my behavior and thinking around the problem. The point is that I now constantly tend to this thing that has been a problem for me. I view it as an ongoing project that will never really be complete.

The analogy I’ll make is to that of an addict. Overcoming addiction is an ongoing process. An addict is either getting better or getting worse but he’s never treading water and staying put. An alcoholic/coke addict/sex addict/shopping addict/whatever-addict is an addict forever. Like an addict, it would probably be more enjoyable for me to quit doing my dinky, boring exercises and tell myself that I’m OK. I could easily do whats comfortable and easy.

I could say, “I’m fine. I’m cured. I don’t need to worry about this problem. It’s behind me forever now.”

If I take that tact though I should expect my problem to creep back in, and I hate that thought.

Losing the ability to run and jump is a powerful source of motivation for me. With proper motivation comes the ability to apply willpower to the problem. With this mindset, the boring and tedious exercises become easy. Doing them isn’t an issue at all now.

As with almost everything we do in fitness (and everything else in the world) the real target here is the brain, not the injured/painful area. If I want continued success and progress then I must decide to take the appropriate action. If I want a specific outcome (Achilles pain gone forever, weight loss, muscle mass, etc.) then I must adopt the behaviors that will get me there. I need to make new habits. That requires conscious thought and deliberate action. The work won’t do itself.

So there.

 

Two Big Reasons to Trail Run (or just hike.)

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I’ve been trail running consistently for several weeks now. I see this as a marker of success in both the continuing rehab of my reconstructed ACL (surgery was May of 2014) and in overcoming stubborn Achilles tendon pain. If all this nice

progress continues, I plan on running the Aspen Golden Leaf half-marathon in October (Damnit!  It’s sold out. I need to move on that earlier next year.) and then the Moab Trail Marathon in November. So all this trail running has me thinking…

Nature & depression

Good for me.   Good for you.

Good for me. Good for you.

An article in the Atlantic titled How Walking in Nature Prevents Depression discusses a study that demonstrates the real psychological benefits to tromping around in the outdoors. Specifically, the researchers found this:

“Through a controlled experiment, we investigated whether nature experience would influence rumination (repetitive thought focused on negative aspects of the self), a known risk factor for mental illness. Participants who went on a 90-min walk through a natural environment reported lower levels of rumination and showed reduced neural activity in an area of the brain linked to risk for mental illness compared with those who walked through an urban environment. These results suggest that accessible natural areas may be vital for mental health in our rapidly urbanizing world.”

When I’m on the trail, I’m very much “in the moment” as the saying goes. I am consumed with the ground and where I put my feet. I’m aware of the plants, the rocks, the temperature, and if I’m in the right spot, I might hear the rush of a stream. I Iam deeply engrossed in the experience. Rarely if ever do I think about the hassles and conflicts that await me in good ol’ “civilization.”

Searing physical exertion is often a part of my trail running experience as well. Despite the pain, I keep coming back. It would seem some part of my brain wants to be there.

Trail running & movement variability

I’ve mentioned the idea of movement variability (here and here). It (to me) is an exciting concept and a hot topic in sports skill training and injury pre-/rehab circles. The smart people at Cor-Kinetic discuss movement variability in this impeccable blog post. The writer states:

Viva movement variability!

“Movement variability is inherent within a biological system. Not only is it inherent it is also beneficial for reducing risk of overload and enabling the ability to adapt to events that occur within our ever-changing environment. Elite athletes cannot reproduce exact and invariant movement patterns repetitively even through hours of devoted practice. The best movers are those that can execute the same stable end point skill but in many variable ways dependant on the constraints and context of performance. It could be that part of being resilient and robust lies in variability. The ability to tolerate load may come in part in the way in which it is internally processed through our coordinative variability.”

If we think about trail running, then we see that it takes place in a highly variable, constantly changing environment. As we run (or walk) we can’t consciously think about how we place our foot every time we step. Rather we must react. This is a job for our subconscious and our reflexes. The movement variability researchers suggest that through this process we may protect ourselves from a lot of potential injuries. (Nothing in the world however can protect us from all injuries.)

On the trail, we have to stay upright, balanced and moving while our running parts deal with all sorts of odd angles and shapes. The great part about negotiating this rocky, rooty, up-and-down environment, is that our feet, ankles, knees, hips—and especially our nervous system—builds what I call a movement database. Our brain soaks up the subtle changes in movement that we experience so we increase our runnings kills. We have an opportunity to as the Cor-Kinetic post says, “execute the same stable end point skill but in many variable ways dependent on the constraints and context of performance.” Our tissues are stimulated in a remarkably well-rounded way so that we become more durable than if we run only on flat, monotonous surfaces.

I’m pleased that I’m not the only one thinking this way. (I’d love to come up with an original thought some day.) Similar observations on trail running are discussed in the Running-physio.com article titled Trail running – Natural rehab?

The writer describes his own experience in trail running:

“Despite running long distances over challenging terrain and including more hills than I’ve ever done before I have far less pain running on a trail than I do on the road.”

And he suggests the mechanism by which this process may work:

“I’m not the only one to find this, so how can trail running reduce pain and help injuries?

It’s all to do with repetitive load – running on a fairly uniform surface stresses the same areas of the body over and over again. Those areas become overloaded and you start to develop pain. Trail running involves a variety of different surfaces – I usually run over grass, mud, gravel and forest ground with treacherous tree roots. This variety means the load on the body is constantly changing rather than overloading certain areas. It may also act as its own rehab – your body adapts to the constant challenges to your control and stability. Running a trail becomes like an advanced balance work out.”

Wisely, he goes on to discuss when trail running may NOT be the right thing for you and how to gradually introduce trail running into your routine.

All of this is anecdotal evidence. I don’t know of any strong studies that show trail running will fix any given injury. That said, a trail run fits the bill very well for a variable movement experience and it’s my belief that many runners who aren’t trail running will benefit from adding some time on the trail into their schedule.

 

The Short-Foot Exercise for Stronger Feet

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Foot/heel/Achilles issues have given me trouble over the years. The same issues are the scourge of many a runner. Plantar Fasciitis, Achilles tendon pain and metatarsalgia are a few of the problems one can experience as a result of faulty foot and lower-leg mechanics.

The causes of these injuries are often multi-faceted and thus are the solution(s). It seems that weakness of the foot muscles may be a prominent issue. One idea on the mechanism of plantar fasciitis is that the intrinsic foot muscles do a poor job of controlling forces going through the foot. If the stresses of running and walking aren’t distributed adequately then we may overstress the plantar fascia and that may trigger pain. We then need to find a way to unload the stressed tissues. (Please note that this may or may not be what causes plantar fasciitis. There are a lot of questions on how this and other lower-limb pain develops. This study discusses the poor understanding of plantar fasciitis and the difficulty in measuring foot mechanics.) If  weak and underperforming foot muscles are part of the problem then how do we bring them back on line?

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Lots of muscles and joints in those feet.

Among many strategies to address foot pain is an exercise known as the short-foot exercise or foot doming. As the name implies, this exercise has you using the intrinsic foot muscles to create a dome by pulling the metatarsal heads (balls of the toes) toward the heel, which shortens the length of the foot.

The short-foot or foot dome exercise.

The short-foot or foot dome exercise.

More than anything this is a brain exercise. Chances are that when you first try this exercise you won’t do it very well. You’ll struggle, steam may come out of your ears and you’ll get frustrated. Don’t be a baby and give up immediately though. This is a new skill and it takes focused attention and time to develop skills. Keep at it. It likely won’t take you very long to figure it out. For me, the challenge of mastering this exercise is nothing compared to the frustration of being sidelined by foot pain.

Also, try the exercise on your non-hurting foot. If you’re like me, you’ll find that it’s easier to do which again may be an indicator that the source of your pain are muscles that aren’t doing their job correctly.

You may experience cramping. That’s fine. It means you’re doing the exercise correctly. You can either relax the foot muscles and try again or do what I’ve done and hold the short foot until the cramping passes. It hurts a bit but I’ve found the pain to pass quickly.

The muscles involved in this exercise aren’t given to being big and strong. We need them to work a lot for a long time, so we need to condition their endurance. Therefore we need to hold the short foot position for time and we need to do the exercise often throughout the day. The good thing is you need no equipment to do this and you can do it anywhere. You don’t have to take off your shoes either.

I think this video does a good job of describing the exercise:

More Hip Mobility From GMB

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I’m a fan of mobility. I put a premium on my clients and I having a large “movement database.” I’m not just talking about flexibility mind you. On that note, I like Dr. Andreo Spina’s words on mobility vs flexibility:

“By my definition, mobility and stability are intimately related. Mobility, which is often confused with ‘flexibility,’ can be defined simply as the ability to move or to be moved freely and easily.  Another way to think of it is the ability to actively achieve range of motion.  Flexibility by contrast is the ability to passively achieve range of motion.  It is therefore possible to be very flexible, however have limited mobility.  The former implies that you can passively achieve a particular range, while the latter implies neurological control of a particular range as it is being actively attained.”

I’m also very interested in the concept of movement variability. What is “movement variability?” Todd Hargrove of Bettermovement.org discusses it as such:

“Good movement is not just about harmonious interaction or coordination between the different parts of the body. It is most fundamentally about how the system interacts with the environment, particularly in response to unexpected changes. In other words, good movement implies a quality of adaptability and responsiveness to a changing environment.

One can imagine building a humanoid robot that can walk with flawless symmetry and grace. But if the robot cannot adapt its gait pattern to accommodate changes in the terrain, it will fall each time it steps on a rock, and its movement skill is essentially useless. True movement intelligence therefore doesn’t exist so much in the movements themselves, but in their interaction with the environment.

The graceful stride of the deer isn’t useful unless it can be modulated to jump a log and avoid a wolf. A soccer player who can execute technically brilliant ball handling skills in solo practice does not face the real test until she performs those moves in a game situation against an opponent who is trying to steal the ball.

We would not say that someone is fluent in a language if they have only one way to communicate a particular thought, regardless of how perfect that particular communication is. Similarly, one is not fluent in the language of movement unless he can accomplish the same goal in many different ways.”

Why do I mention movement variability? My last blog post was about hip mobility and in it were several different hip mobility drills. This post is also about hip mobility and it features a bunch of different drills. Which ones are best? Who knows? With regard to movement variability, I think it’s probably a good idea to do a lot of different mobility drills and frequently experience novel movement.

Recently I discovered GMB.io.  (Yes you read that right.) I’m not sure what GMB stands for but I have enjoyed looking through their content which is very much mobility-centric. Their 8-exercise hip mobility sequence (below) is great! I’ve been using myself and with my clients. Lately I’ve been alternating between this series and the series in the prior post.

 

 

 

More Achilles Tendon-itis/-osis/-opathy (or Whatever It Is)

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About three weeks ago I went for a run in the snow. Part way through I felt some irritation in my left Achilles tendon. Like anyone who loves/needs to exercise, I kept running and I tried to convince myself that it wasn’t too bad, that it would probably go away soon or maybe if I changed my stride slightly it would resolve during the run.

I was wrong! I really irritated the thing and had to walk about a mile. This was the latest flare-up of a years-long lingering issue. (I’ve discussed the Achilles here and here, as well as left heel pain/plantar fasciitis hereherehere, here, here and probably in some other places… You’d think for someone who’s considered this issue so much that I wouldn’t have it anymore.)

Prior to this Achilles flare-up, I’d had some of some old familiar heel pain. It wasn’t debilitating but it was a signal that something wasn’t as it should be. Again, I ignored it to a large degree and figured it would resolve. I should’ve paid closer attention to it. Essentially, it wasn’t a problem until it was a problem. Time to get back to work on this thing.

Tendon injury: A complex issue

Why do we get injured? How do our tissues (like tendons) become damaged? If we administer the right amount of stress and then recover we get a positive adaptation–we get stronger. In contrast, if we administer too much stress and we don’t recover then we get some type of injury. Thus too much stress delivered too often and/or too fast has been my problem. I need to increase my tissue tolerance to the forces of running.

A recent article from Alex Hutchinson is titled Pro Tips on Treating Tendon Injuries. This article covers a debate among members of the Canadian Association of Sports and Exercise Medicine in Ottawa. Several top sports physicians and therapists were asked: Which therapy should the squash player try next? (I’m not a squash player but I have the injury they discussed.) If you’re dealing with this issue it’s definitely worth a read. It discusses several methods: eccentric strengthening, nitroglycerin patch, dry needling, cortisone, and platelet-rich plasma.

There wasn’t 100% agreement on anything much, but Hutchinson’s concluding statement was this (emphasis is mine):

“So what should the poor squash player do? In the question period following the debate, most participants conceded that strengthening exercises are the path to long-term health. Depending on the specifics of your tendon injury, other techniques may provide relief to allow you to exercise, but they’re not permanent cures.”

Cures I like. I have no interest in simply treating symptoms. Thus I decided it was time to implement something with which I’d been familiar but which I knew wouldn’t be very exciting at all: the eccentric strength protocol.

Eccentric strengthening

First, what does “eccentric” mean?An eccentric contraction is one in which the muscle is contracted but it’s also lengthening. Think of doing a bicep curl. You know the part where you yield to gravity and lower the weight? That’s the eccentric portion of the movement. (In contrast, the concentric portion is where you overcome gravity and bring up the weight.) For this particular protocol, we want to fight against the lowering action and lower very slowly.

I found a very thorough resource for this project from Jeff Gaudette at RunnersConnect.net. It’s titled The Ultimate Runner’s Guide to Achilles Tendon Injuries: The Scientific Signs, Symptoms, and Research Backed Treatment Options for Achilles Tendonitis and Insertional Achilles Tendinopathy. (The title of this thing just screams ACTION!! doesn’t it?) You can download both the Injury Treatment PDF and the Injury Prevention PDF. As the title suggests, this is a thoroughly researched guide to dealing with tendon injuries. I appreciate very much that there is both a treatment and prevention strategy. I won’t go into the whole thing but here are the basics:

The strength protocol consists of two exercises: a straight-kneed and a bent-kneed
eccentric heel drop. The protocol calls for three sets of fifteen heel drops, both bent- kneed and straight-kneed, twice a day for twelve weeks.

Standing on a step with your ankles plantarflexed (at the top of a “calf raise”), shift all of
your weight onto the injured leg. Slowly use your calf muscles to lower your body down,
dropping your heel beneath your forefoot. Use your uninjured leg to return to the “up”
position. Do not use the injured side to get back to the “up” position! The exercise is
designed to cause some pain, and you are encouraged to continue doing it even with
moderate discomfort. You should stop if the pain is excruciating, however.

Once you are able to do the heel drops without any pain, progressively add weight using a backpack. If you are unlucky enough to have Achilles tendon problems on both sides,
use a step to help you get back to the “up” position, using your quads instead of your
calves to return up.

The eccentric exercises are thought to selectively damage the Achilles tendon, stripping
away the misaligned tendon fibers and allowing the body to lay down new fibers that
are closer in alignment to the healthy collagen in the tendon. This is why moderate pain
during the exercises is a good thing, and why adding weight over time is necessary to
progressively strengthen the tendon.

You do these exercises for 3 sets of 15 reps, twice daily. There are photos showing these exercises including a modification if you have what’s known as insertional Achilles tendonitis. Again, read the whole thing if you want the full rundown of this protocol.

More thoughts

Part of why I haven’t done this in the past is that it is slow and tedious! Three sets of 15 slow reps makes time crawl like some sort of crippled tortoise. It ain’t fun! Plus I’ve never cared much for doing calf work. That said, I need to fix this problem. This process seems to be the best way to go about it, so I’m on board.

Something else I realize is that if I’m prone to this injury and I want to avoid it then I need to do the preventive work. That means setting aside time throughout the week and during my workouts to do some of this stuff.

I’ve been doing this work for about the past three weeks and I am getting better. I’ve done a couple of short run/walks and I’m not in the clear just yet. The only option I see is to continue doing what I’m doing.

Update

I just went on a run of a little over two miles and the Achilles feels fantastic. No pain! Felt like I could’ve run all day–which would’ve been stupid of me. This protocol is working for me right now.

Activity is Better Than Rest for Overcoming Lingering Pain

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I’m glad to see Outside Magazine delivering a message that may be very useful to anyone suffering from pain. (This is from 2009, but I just saw it.) The article mirrors my recent experience with my ACL rehabilitationThe Real Heal: Overcoming Athletic Pain says two things essentially:

  1. Rest usually doesn’t cure what hurts us. (In fact, too much rest makes us deconditioned and contributes bad feelings in general.)
  2. Moving and using our sore parts–confronting the pain–is essential to getting rid of pain.

The writer discusses his journey following a bike crash which hurt his knee (an acute injury). He rested and took pain medicine. He states (emphasis is mine):

“It turns out my belly-up approach was dated. New research is proving that the best way to treat nagging pain is to eschew pampering in favor of tough love. Doctors at the University of Pittsburgh are doing ongoing research showing that stretching irritated tendons actually reduces inflammation. And the principle extends beyond rickety wiring. Every expert I spoke with told me variations of the same thing: ‘Rest and ibuprofen cure few injuries,‘ said Dr. Jeanne Doperak, a sports-medicine physician at the University of Pittsburgh. ‘During rest you’re in a non-healing zone,‘ offered Dr. Phelps Kip, an orthopedic surgeon and U.S. Ski Team physician. ‘The body was designed to move.'”

Pain is very much a psychological thing. I can relate to this:

“And it just so happens that tendinopathy chronic tendinitis is the most diabolical of recurring injuries. Give me a broken foot over tendon trouble any day when something snaps, at least you know what you’re in for. My injury dragged on into winter, deep-sixing my mood. This is not uncommon: The link between pain and depression is so well established that sports psychologists use a tool called a Profile of Mood States to monitor injured athletes. (This is a graph evaluating tension, depression, anger, vigor, fatigue, and confusion. People in pain score extremely high in every category except for vigor.) I was five years removed from being a college athlete and I was Long John Silvering it up stairs at work. Strange questions crept into my head: Could I consider gardening exercise?”

I like the overall message of the article but I don’t agree with all the information:

  • The writer says, “… or imbalances in the body’s kinetic chain of movement (a weak core can cause lower-back pain).”

Though this is a popular concept, there is significant evidence that “core strength” (which can be defined and measured in a multitude of ways) has nearly nothing to do with back pain.

  • For runner’s knee, the writer suggests this: “Lie sideways on a table, legs straight, and slowly raise and lower the upper leg ten times. Do three sets. Easy? Ask your PT for a light ankle weight.”

I think this might be part of an effective strategy to address runner’s knee (if the problem is rooted in the hip which it often is; however it could be rooted in poor control of the foot and ankle), but there are several dots that I think need connecting between this exercise and full-on running. This exercise is very different from running in which the foot impacts the ground and the runner must control motion at the foot, ankle, knee and hip. If this is the only exercise given to a runner’s knee patient then I’m skeptical that the runner will fully overcome the issue.

  • A caption under a photo reads, “Preventive Measures: Recovering from a nagging injury? Next time you go for a run or a ride, try taking ibuprofen beforehand. As long as you’re cleared for activity by your doctor, inhibiting swelling prior to a workout can dramatically reduce post-exercise inflammation and pain.”

This is an interesting idea but I have strong reservations. Pain is a signal that should be respected. Even though pain doesn’t equal injury it’s still a message from our brain that there is a perceived threat that needs to be addressed. The pain could be signaling a threat related to poor movement control and tissue stress is leading toward injury. By taking a pain-blocking drug, we might simply be turning down that signal as we continue with what may turn into an acute injury. I would compare this to driving a car with a damaged muffler that needs replacing and instead of replacing the muffler, we turn up the stereo loud: No noise!!–but have we fixed the problem?

On the other hand, I understand that even if the movement problem is addressed, we may still feel pain. Taking a drug may help the brain experience the new, better movement in a painless way which might help break the chronic pain cycle. I’m curious to what degree this has been method has been investigated.

For me, as a personal trainer, I would never suggest someone take a drug and just keep going. Rather, I would speak with the person’s PT. If he or she OKs it, I would then advise someone to move and work below the pain threshold or at a very manageable level of pain.

Pain, the Brain and ACL Recovery

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A few weeks ago I had a very interesting experience regarding my ACL rehabilitation. It’s very similar to an experience I had with Achilles tendon and heel pain. Here it is.

A perceived setback

I had ACL reconstruction on May 1, 2014. I have been very aggressive with my rehabilitation and I felt it was going very well. My PT and I agreed on a strategy and he approved of the process in general. I knew that sitting and resting was not the right way to go if I wanted to regain full function. For people like me, laziness wasn’t a problem; an overly aggressive approach might be though.

I knew that I could be in trouble if I did too much work too fast and stressed the knee too much. I worried that I’d drifted into this territory when at almost nine months I experienced more pain than I expected. I had a final appointment with my surgeon and she expressed some concern at my symptoms. We agreed that I should back off my activity and rest a bit. Seems perhaps I had reached the point of “too much of a good thing.”

I backed off lifting, running a cycling. I didn’t stop my activity completely but I cut it back significantly. After a couple of weeks I realized the knee wasn’t feeling much better. I continued to experience frequent pain; not debilitating but somewhat worrisome. I decided a visit to the PT was in order. I wanted to get some guidance and make sure I hadn’t damaged the graft.

The long and the short of the visit was this: The graft and my knee were fine. I needed more strength in the leg and around the knee. I needed to do more work, not less! Eureka! (My previous PT had moved on to another position and I had to meet with a new one. Unfortunately, the “bedside manner” of this PT left much to be desired. Right off the bat she was rude, dismissive and she interrupted my answers to her questions. I became very frustrated and it was work to keep my yapper shut and listen to what I needed to. Fortunately I got the information I needed.)

From here, I was ready to rock ‘n’ roll.

Goodbye fear. Hello confidence!

My experience was a very clear experience of what modern pain science has been finding recently. Here are some important points:

1) Pain doesn’t equal injury: In Reconceptualising Pain According to Modern Pain Science, neuroscience researcher Dr. Lorimer Moseley has made several points about pain. Two are pertinent here:

  • pain does not provide a measure of the state of the tissues
  • The relationship between pain and the state of the tissues becomes weaker as pain persists.

Yes I had an injured knee and yes I had surgery in which part of my patellar tendon was cut out in order to make a new ACL. This was all very disruptive to parts of the knee and was clearly part of the pain I was feeling. It takes about six weeks for the graft to heal. The reconstructed ACL is pretty much healed at six months which would’ve been October for me. In other words, my knee was/is healed and any pain wasn’t from tissue damage.

2) Fear is a significant obstacle that must be addressed: Fear is a powerful part of our pain. Overcoming that fear is major part of a successful rehab and return to activity. The pain in my knee caused me to worry that I’d re-injured it and it led me to avoid a lot of activity that I enjoyed. This condition is known as fear-avoidance. The International Association for the Study of Pain (IASP) describes fear-avoidance this way:

Psychological factors play a key role in the development of chronic musculoskeletal pain, in particular dysfunctional beliefs about pain and fear of pain. Fear of pain leads to avoidance of activities (physical, social, and professional) that patients associate with the occurrence or exacerbation of pain, even after they may have physically recovered. Whereas this response is adaptive in the acute phase—rest promotes recovery—it leads to disability and distress when avoidance behavior is continued after the injury has healed.

"Fear-avoidance model" by LittleT889 - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Fear-avoidance_model.jpg#mediaviewer/File:Fear-avoidance_model.jpg

“Fear-avoidance model” by LittleT889 – Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Fear-avoidance_model.jpg#mediaviewer/File:Fear-avoidance_model.jpg

When I learned that my parts were solid and strong and that I wasn’t broken, I felt the fear drain away like water down a toilet. I was a happy dude!

Another of Moseley’s points is important here: that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

Big words. What does that statement mean? I’ll let Moseley explain (emphasis is mine):

First, there are other central nervous system outputs that occur when tissue is perceived to be under threat, and second, that it is the implicit perception of threat that determines the outputs, not the state of the tissues, nor the actual threat to the tissues.

In even simpler terms, we may feel pain absent any damage but we feel pain when our brain perceives a threat–even when there is no threat. I compare this to a car alarm that is set off by the wind. There’s no break-in occurring yet the alarm signal is going off due to the alarm sensing a threat.

3) Patient education is vital: Very interestingly, an effective strategy in treating chronic pain is patient education. This strategy of patient education is supported in several studies that are discussed in a review in the Archives of Physical Medicine and Rehabilitation, and it’s further discussed in an article titled Can Pain Neuroscience Education Improve Endogenous Pain Inhibition? Literally, knowledge of pain processes can reduce pain. (Pain is weird!) I believe that my experience supports this phenomena.

(To be clear, it’s not that I received education on how pain works. I received the message that my knee was solid, not injured and that it could be worked very hard.)

Keep this in mind.

Dr. Moseley discusses pain education in Pain really is in the mind, but not in the way that you think. I like what he says here:

“The idea that an inaccurate understanding of chronic pain increases chronic pain begs the question – what happens if we correct that inaccurate piece of knowledge?

We’ve been researching the answer to this for over a decade, and here’s some of what we’ve found:

(i) Pain and disability reduce, not by much and not very quickly but they do;

(ii) Activity-based treatments have better effects;

(iii) Flare-ups reduce in their frequency and magnitude;

(iv) Long-term outcomes of activity-based treatments are vast improvements.”

Most of us outside the medical community probably still equate pain to damage. Many inside the medical community still think that way too. (Blame Rene Descartes.) We now know better. Rather than address pain from a strictly biomechanical approach, therapists would be well advised to study and adopt what’s known as the biopsychosocial model for pain. This model is explained very well here and discussed in-depth here. We patients will be well armed in a fight against pain if we understand this model too.

 

What I’ve Learned: Principles of Movement & FASTER Global – Part IV

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I’ve been discussing movement, exercise and how to make traditional exercises more applicable to real-life and athletic activities. I’ve discussed going from two feet to stepping.  From there we can progress to a variety of hops and jumps.

Progressions

  • 2 feet to 1 foot
  • stationary to stepping to jumping
  • jumping from two feet to two feet
  • jumping from two feet to one foot
  • jumping from one foot to one foot
  • stepping and jumping may occur in saggital, frontal or transverse planes
  • add weight

Other things to think about

We could focus on “sticking” the landing and maintaining perfect balance and control or we might focus on moving very quickly from one hop/jump to the next.

We might emphasize a very long or very high jump/hop or we might emphasize short and fast hops/jumps.

Here are some videos featuring tri-plane jumping and hopping with all sorts of arm driver activity. These are in no particular order and I’m not showing a progression. These are just a few combinations.

There is a nearly endless galaxy of these types of exercises. Any number of implements can be used (Core Momentum Trainer, dumbbells, sandbags, kettlebells, nothing at all). Trainees can either stay stationary or move in any direction.

I’m in the advanced stages of ACL rehabilitation and I’m using a lot of these types of exercises in my own workouts. I’m using them with a lot of my clients who are athletes as well as clients who don’t consider themselves athletes. These exercises can be a lot of fun, feel very challenging and are useful in stimulating the metabolism for those wanting to lose weight.

What I’ve Learned: Principles of Movement & FASTER Global – Part III – Lunge and Reach

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In the previous two posts, (here and here) I discussed what I’ve learned by going through the FASTER Global coursework. (If you’re a fitness professional who wants to truly become an expert at movement, then you need to do this course. This has been the most comprehensive movement education I’ve had in nearly 20 years of working in the fitness field.)

I believe I’ve made the case for why we should train with tri-plane movement. Further I believe that I’ve illustrated why traditional gym exercises like squats and deadlifts may not be the best way to develop all-around movement skills or strength.  (For the record, I’m not saying traditional squats and deadlifts are bad. I use them in my own workouts and with my clients. To be clear, I believe that there are infinite variations that can and should be used to condition people in the most comprehensive way.)

In the previous post I showed a bunch of lunge and squat variations. Here are some more lunge variations this time with arm reaches.

Lunging and reaching

While lunging, we can drive motion from the upper body by reaching up, down, across, overhead, etc. We can reach with one or both arms. The way in which the trainee steps drives motion from the upper body up through the rest of the body. As he or she reaches, motion is driven down through the body toward the ground. The reaching affects balance and creates a wide range of slightly different body positions which look a lot like any number of athletic activities, for example, look at the baseball pitcher and basketball players.

Lower body motion plus upper body motion.

Saggital plane anterior lunge with same-side posterior arm reach… Or something like that. Lots of stuff happening.

Kobe executes a type of lunge and reach down.

Kobe executes a type of lunge and reach down.

Resistance can be added to these in numerous ways: weight vest, dumbbell(s), sandbags, kettlebells, etc. Cables or tubing positioned at any number of angles can speed up or slow down the lunge.

Remember though, if someone can’t control these exercises then he or she should be regressed to something that is controllable, safe and manageable.

Here are a few examples of lunges combined with reaches in various directions. I’ve shown an anterior lunge and a lateral lunge but we could add any of these reaches to any type of lunge. The combinations are nearly infinite.

Next we can progress to jumps and hops, all done in any number of directions, all with feet and arms in any number of positions. I’ll show some of those in the next post.