Most anything from Pavel or Dan is worth reading and understanding.  Easy Strength is no exception.  The book is more than just a bunch of different workouts.  Four quadrants are examined in which an athlete might find him or herself during a career.

Quadrant I sees the athlete (often a kid) introduced to all sorts of games, exercises and movements.  This quadrant is an inch deep and a mile wide.  An athlete in Quadrant II may play a specific sport which requires a mix of strength, speed, mobility, endurance, etc.  Think basketball, football, soccer, wrestling…  An athlete in this quadrant must work on all these qualities and thus can’t be the best at any one quality.  The athlete must live with compromises.  Quadrant III is where most of us live.  We’ve narrowed our focus to a few things but we’re not world champs.  Quadrant IV is for pinpoint specialization.  Here you’ll find weightlifters, sprinters, elite distance athletes, etc.  These athletes have a very narrow focus and thus have very narrow training needs and requirements.  The authors refer back to these quadrants throughout the book, and give considerations for the training needs of each of these athletes.

A quick word on the word “stronger.”  It doesn’t necessarily equate to “bigger.”  Many athletes (and everyone else on earth) need strength but not lots of muscle mass.  Easy Strength takes this into account.  Meanwhile some readers do want more muscle mass.  This issue is also discussed in the book.

Oh, and the book is also chock-full of all kinds of workout programs and reasons to use them.  A continual theme throughout the book is “less-is-more,” and the workouts reflect this idea.  The problem is there are so many interesting workouts that like me, you may find yourself wanting to do “this one and that one and that one and that one too!”  Pavel and Dan would tell you to pick one and stick to it.  Get all you can out of it then move to another workout.  Don’t blend this one with that one.  So I picked one.  It’s the 40-Day Workout.  The workout is similar to the Power to the People deadlift workout.  For a very thorough description of this workout read Dan John’s blog post called Even Easier Strength.  Here’s the basic rundown:

Pick five exercises: a press, a pull, a hinge (deadlift, kettlebell swing, Romanian deadlift), a squat, a loaded carry, possibly an ab movement.  (A pull and a hinge may be combined as in a deadlift for instance).

Do these exercises five days a week.  Do about 10 reps per exercise.  That may come in sets of 2×5 reps, 5×2 reps, 3×3 reps, six singles or other combinations that come out to about 10 reps.  Work hard–but not very hard.  These workouts are practice, not a red-line suffer-fest.  The workouts should feel fairly easy.  You should feel strong at the end of your workout, not flattened and half-dead.  Don’t max out on reps or weight but rather nudge the weight up gradually as you move through the 40 days.

I’ve taken about a month off from lifting.  My goal is to get stronger generally and a little more muscular.  My workout looks like this:

Warm-up: Z-Health mobility work, core activation, jump rope, kettlebell swings, body weight lunges/squats, med-ball throws or some combination of these.

Main lifts:

1. Front squat
2. Barbell overhead press supersetted with face-pulls, batwings and some band pull-aparts
3. Deadlift
4. 1-arm farmer walk
5. strict leg lifts
   (Technically there are more than five exercises here, but the additional shoulder exercises are supplemental exercises, not heavy main lifts.)

To get a little bit of a cardio boost I go through the work as fast as I can–but not too fast.  I rest as needed but I’m pretty much lifting as quickly as I can load and unload the plates.  I’ll take more rest as the weights get heavier.

I’m really enjoying this workout.  I get to lift every day.  I don’t kill myself doing it and it’s fun to add a little weight each time.  Plus it’s simple.  I don’t have to mind too many variables.  A couple of my clients are playing with this workout as well.

Easy Strength is a great read.  It’s fairly profound in its message with extremely valuable information from the most experienced strength coaches in the world and reasonably easy to understand.  If you’re even semi-serious about getting stronger–as any human should be–you need this book.

“About two-thirds of the group wound up hurt seriously enough each year to miss two or more training days. But the heel strikers were much more prone to injury, with a twofold greater risk than the forefoot strikers. (Emphasis is mine.)”

Be careful though.  This finding doesn’t necessarily mean that everyone should immediately change their running form.  The article quotes says:

“Does this mean that those of us who habitually heel-strike, as I do, should change our form? “If you’re not getting hurt,” Dr. Daniel Lieberman says, “then absolutely not. If it’s not broke, don’t fix it.”

But, says researcher Adam I. Daoud, who was himself an oft-injured heel-striker during his cross-country racing days, “if you have experienced injury after injury and you’re a heel-striker, it might be worth considering a change.”

For further discussion and analysis on these findings, have a look at Runblogger’s post (and how these findings are being misused in advertising) and the post at Sweat Science.  Both of these guys do a great job of telling us what the data does and does not show.

Hello spine.

Anatomy

Your spine or vertebral column normally consists of 33 bones.  You have seven cervical vertebrae in the neck region, 12 thoracic vertebrae that make up the mid-back, and five lumbar vertebrae that make up the low back.  Down at the very bottom you’ve got the sacrum and the coccyx, aka the tailbone.  So think of your t-spine as starting from the base of your neck and ending on an even level with the top of your hip bones.  So why should you care about this region?

The thoracic spine is built for movement.  This part of our spine was made to twist, flex forward and sideways, extend back plus a combination of all the above.  But look at the modern Western lifestyle: We sit and we hunch.  We hunch at a computer.  We hunch over a steering wheel.  For fun, we hunch in front of a TV.  If we’re cyclists, then we hunch even during our athletic event.  If we play golf or softball then we get rotation but generally only in one direction. In other words, the t-spine spine gets very little movement.  What are the implications?

Organ function
It’s fairly obvious that most of our internal organs rest near our t-spine. Those organs are innervated by nerves that exit out of the thoracic spine.  This means those organs send and receive information to and from the brain by way of the t-spine. Have a look at the chart and notice which organs receive their nerve supply from the t-spine region.

Your organs' sources of nerve innervation

If this part of your spine is immobile then you could have compromised organ function.  That could mean anything from hand and wrist pain to breathing issues, thyroid issues, heart dysfunction, kidney dysfunction, digestive trouble, and who-knows-what-else.  Thus mobilizing this area may well improve organ function.

Limb function & pain issues (or avoidance thereof)

Proper t-spine movement is tied very strongly to good shoulder and arm function and to good low-back health.  (I’ve had personal experience with this, both with my own pain issues and with various clients.)  A gunked up t-spine means the shoulders are going to move badly.  A tight t-spine will likely result in shoulders that are unstable.  Thus the shoulders may pay the cost of poor t-spine movement.  Similarly with the low-back.

The lumbar spine is not a terribly mobile part of the body.  It has about 6-7 degrees of rotation in each direction. The t-spine however has about 35 degrees of rotation each way.  Your entire spine rotates as you walk, run, swim, reach behind you and obviously if you golf, swing a bat or throw a punch.  If you lose t-spine rotation then your lumbar spine will likely start to compensate and rotate more than it was designed to.  So that low-back pain you keep heating and icing and stretching, etc?  It very likely may be caused by poor t-spine movement.

Appearance

Why do most of us work out?  We may say “just to be healthy” or “my doctor told me to, but the real honest reason most of us exercise is for looks.  There’s nothing bad about looking good!  Good t-spine movement and positioning can help you look better instantly.

Remember that we’re a hunched over society.  Look around you.  How many rounded shoulders do you see?  This doesn’t look great.  Imagine if people drew themselves up, lifted their collarbone, and lengthened their spines.  No question but that we’d look stronger, healthier and more attractive.

Okay, so there’s some info on what your t-spine is and why proper movement is vital.  Now it’s time to move!  (Please pardon the discrepancy between the audio and video.  I’m trying to figure out what the problem is.  Youtube is a challenge for some reason.)

“With it went my belief, naïve in retrospect, that yoga was a source only of healing and never harm.”
- William J Broad, NY Times

If you haven’t read or heard about it, the New York Times recently ran an article titled How Yoga Can Wreck Your Body.  It’s far from the perfect article.  For one, it’s full of anecdotal evidence.  Second, many of the examples given of yoga causing injury consist of people doing rather extreme versions of a pose or movement.  I think the article does bring up valid questions: Can yoga cause harm?  Is it always safe for everyone?

I’ve had a couple of harsh experiences with yoga.  Once I had a teacher that thought since I looked big and strong I could do some sort of headstand.  I figured I would follow the teacher’s lead and give it a shot.  Without question I was not ready for this pose.  I left the class with a very painful shoulder.  This instructor had been teaching for years and was very highly sought after at the gym where I worked.  I was in another class where an instructor all but insisted that I move deeper into a pose and I simply couldn’t do it.  My nervous system was trying to protect me by preventing further movement into this position and she had me trying to force my way into a deeper range of motion.  Again, by the end of class, I was in a bit of pain.  This is not what I was after.

My observation is that yoga is often championed as a panacea cure-all for any number of ailments: back pain, knee pain, mental stress, possibly even digestive issues.  I can’t say everyone says this type of thing but in every gym setting where I’ve worked yoga is discussed and presented in this glowing fashion. But is yoga really any different from any other type of exercise? Might there be a few risks?

First and foremost, yoga is movement.  So is running a 100 m sprint.  Driving a golf ball is also movement.  The power lifts are movements.  Typing on a keyboard and watercolor painting?  Also movement.  Guess what: Movement can cause injury!  (By the way, try NOT moving and see how healthy you become.)  Further, yoga is a lot of very different movements.  One may be quite safe, another quite unsafe.  All parts of yoga can’t be viewed fairly as the same thing.

We can probably agree that movement is essentially necessary and usually healthy.  We can probably agree that walking is typically safe and healthy.  But what if we have a sprained ankle?  Or a damaged vestibular system such that we can’t tell which way is up?  Then even walking might be quite harmful.  Lifting weights is similarly healthy in most cases.  If we have a herniated disk or if we use bad technique then lifting may be very unhealthy.  Why would we view yoga as any different?  If we have poor kinesthetic sense then moving into any number of poses could cause pain and/or injury.

Further, we as Americans often have the view of “If a little bit is good then a BIG WHOLE LOT must be great!” More is better in other words. I’ve heard some yoga people speak proudly of not only how deep they can move into a pose but also how quickly they can move from one pose to another.  Sounds a lot like the talk in any weight room.  Just substitute weight and reps for poses and depth of motion.

Glenn Black is an experienced yoga teacher who’s interviewed for the Times article.  He speaks to other yoga teachers and practitioners on the issue of injuries.  He talks about ego.  (I think the popular image of yoga is that it is an ego-less type of thing.  But what human activity is free of ego?)  Black says, “My message was that ‘Asana is not a panacea or a cure-all. In fact, if you do it with ego or obsession, you’ll end up causing problems.’”  This seems a very wise statement, and I’m pleased that this article may start to shed light on the idea that yoga should be evaluated the same way as any other type of exercise.

I call this portrait "Health Food."

I grew up in the years of the low-fat craze.   We were told that reducing dietary fat and cholesterol—particularly animal fat—was the best way to lose weight and improve our health.  We saw wide scale proliferation of fat-free and reduced-fat food products.  These products were then stuffed with sugar and weird chemicals that were and are very detrimental to our health—but hey!!—there wasn’t any fat.  Ironically, this low-fat era saw an exponential expansion of  American’s waistlines and all the associated chronic diseases such as heart disease, diabetes and cancer.

Now we’re seeing that a lot of our dietary guidelines were way off the mark. Turns out in fact that a lot of those guidelines were based on very shaky evidence and that researchers of the time were not in agreement on the data.  A very thorough look at this evolution of our dietary guidelines can be found at the City Journal in an article titled The Washington Diet. Here’s an excerpt:

“As science writer Gary Taubes notes in Good Calories, Bad Calories, Senator George McGovern’s Select Committee on Nutrition and Human Needs, in coming up with its diet plan, had to choose among very different nutritional regimes that scientists and doctors were studying as potentially beneficial to those at risk for heart disease. Settling on the unproven theory that cholesterol was behind heart disease, the committee issued its guidelines in 1977, urging Americans to reduce the fat that they consumed from 40 percent to 30 percent of their daily calories, principally by eating less meat and fewer dairy products. The committee also advised raising carbohydrate intake to 60 percent of one’s calories and slashing one’s intake of cholesterol by a quarter.

Some of the country’s leading researchers spoke out against the guidelines and against population-wide dietary recommendations in general. Edward Ahrens, an expert in the chemistry of fatty substances at Rockefeller University, characterized the guidelines as ‘simplistic and a promoter of false hopes’ and complained that they treated the population as ‘a homogeneous group of [laboratory] rats while ignoring the wide variation’ in individual diet and blood chemistry. The Food and Nutrition Board of the National Academy of Sciences released its own dietary suggestions, which saw ‘no reason for the average healthy American to restrict consumption of cholesterol, or reduce fat intake,’ and just encouraged people to keep their weight within a normal range.”

Practical information

The very strong and very thoughtful lads at T-Nation.com give us a simple and worthwhile article on fat titled Fats Made Simple.  This article goes into the various attributes of different fats and oils, which are best to cook with, which ones are best used as a topping, and which ones to avoid altogether.  The issue of Omega-3 and Omega-6 fatty acids is discussed.  I won’t go into every detail but here are some key points from the article:

– Use saturated fats for cooking.  These are less likely to become rancid and toxic during the cooking process.

– Use unrefined oils.  DON’T use refined oils.

The author’s top 6 oils are:

–red palm

– coconut

– macadamia nut

– extra virgin olive

– hemp seed

– walnut

AVOID THESE OILS:

– safflower

– sunflower

– canola

– corn

– sesame

– peanut

– pistachio

– pumpkin

– soybean
(Next time you’re looking at ingredient labels, see if you spot any of these oils–particularly corn, canola and soybean.  Chances are you’ll find at least one if not several.  They’re in everything!)

An eating plan

The Perfect Health Diet is an example of a a diet that’s high in healthy fat.  It was developed by two scientists who wanted to address some of their chronic health issues.   This plan has adherents eating about 2/3 plant foods and 1/3 animal-based food.  Besides a high fat content, the diet is further characterized by complete avoidance of sugar and cereal grains such as wheat, corn and oats; this due to their inflammatory nature.  (If you cut out the processed food then you’ll cut out a lot of sugar, wheat, corn etc).  Legumes such as soy and peanuts are also to be avoided as well. Here are more details of the diet.

Please take note, dietary animal fat should come from free-range grass-fed sources.  Most of the mass-produced grocery store meat is chock full of garbage such as added hormones and antibiotics.  Plus the animals are fed stuff they’re not meant to eat.

I’m currently on this eating program.  Admittedly, I haven’t followed it 100% but I’m working in that direction.  I definitely feel more energetic having reduced my grain intake.  I realize when I do consume grain, I tend to get a bit bloated.  The odd thing is eating and really enjoying a lot of foods that for years I thought were really bad for me: butter, bacon, whole eggs, chicken with the skin on it, organ meats.  I’m quite interested in sticking with this plan, further “perfecting” my eating, and seeing where it takes me.

“Hopefully now you understand that damage and soreness are not necessarily bad things, but instead are essential triggers for the adaptations we all seek to improve performance.”
- Steve Magness, Running Times

The previous post on supplements got me thinking about various articles I’ve read recently on the possible negative effect that antioxidants may have on endurance training.  Here is some information to consider.

Alex Hutchinson writes a blog called Sweat Science.  He also writes a column called Jockolgy for the Toronto Globe and Mail and he’s written articles for the New York Times, Runner’s World and Popular Mechanics.  Beyond that he’s your ordinary, every day physicist and elite-level distance runner.  Seems like a smart guy to me.  I listen to what he has to say.

He recently wrote a piece titled The case against antioxidant vitamin supplements.  It’s of a similar theme as an earlier post called Does Vitamin C block gains from training? Both posts suggest the idea that supplementing with antioxidants may inhibit the training effects we want from strenuous workouts.  This may seem counter to what many of us have been told.

Science tells us that antioxidants protect us from cellular damage done by free radicals.  Free radicals are produced by strenuous exercise.  So recent conventional wisdom says that we can protect our bodies by taking antioxidant supplements such as Vitamins C and E.

New research though is telling us that our supplementation may be interfering with the cycle of stress and adaptation that a workout provides.  Hutchinson refers to research in the latest issue of Sports Medicine that supports this concept.  He cites the following (The ROS mentioned are free radicals.):

“The traditional theory goes like this: strenuous exercise produces “reactive oxygen species” (ROS), which cause damage to cells and DNA in the body. Taking antioxidant supplements like vitamins C and E helps to neutralize the ROS, allowing the body to recover more quickly from workouts.”

“The new theory, in contrast, goes like this: strenuous exercise produces ROS, which signal to the body that it needs to adapt to this new training stress by becoming stronger and more efficient. Taking antioxidant supplements neutralizes the ROS, which means the body doesn’t receive the same signals telling it to adapt, so you make smaller gains in strength and endurance from your training.”

“The new paper comes down firmly on the side of the latter view:”

“The aim of this review is to present and discuss 23 studies that have shown that antioxidant supplementation interferes with exercise training-induced adaptations. The main findings of these studies are that, in certain situations, loading the cell with high doses of antioxidants leads to a blunting of the positive effects of exercise training and interferes with important [reactive oxygen species]-mediated physiological processes, such as vasodilation and insulin signalling.”

The researchers conclude with the following statement:

“We recommend that an adequate intake of vitamins and minerals through a varied and balanced diet remains the best approach to maintain the optimal antioxidant status in exercising individuals.”

All of these ideas and observations are similar to the views expressed by exercise scientist and running coach Steve Magness in his article When Damage is a Good Thing in Running Times.  His article discusses not only antioxidant intake but also ice baths, anti-inflammatories, and carbohydrate drinks.  If you’re an endurance athlete then you should definitely read the article.  Magness sums up things well with the following statement:

“Hopefully now you understand that damage and soreness are not necessarily bad things, but instead are essential triggers for the adaptations we all seek to improve performance.  The goal should not necessarily be to minimize them automatically, but instead to work with them–this means allowing for enough damage to take place to initiate adaptation and then allowing for the body to go through its natural recovery response before trying to aid recovery.  The goal should be to work with the body, not against it.  So keep in mind the goal of each training session and the goal of whatever recovery methods you use, and plan things accordingly so your recovery efforts help you to improve performance, not hinder it.”

Incidentally, all of this has caused me to rethink my recovery strategies.

• 5:45 pm, Tuesday, December 6th
• 9:30 am, Thursday, December 8th

This is an interactive lecture so you will be moving around.  It’s not a full-on workout by any means but please wear clothing that will allow you to move comfortably.

For more information call the Cherry Creek Club at 303-399-3050 or you may email me at DenverFitnessJournal@Gmail.com.

Vitamin E and prostate cancer

First, some information from an article in the Atlantic called Are Supplements Killing You? The article looks at two studies.  The SELECT study is the first one discussed.  The results of the trial were recently published in the Journal of the American Medical Association.  The aim of the study was to see if Vitamin E and/or selenium supplementation offered a protective effect from prostate cancer.  The study followed 35,000 men aged 50 and up split into three groups: one group took Vitamin E, one group took selenium, one group took both.  Participants were tracked from 2001 to 2008.  The study was stopped in 2008 because rather than finding a protective effect, there were indications that cancer risks were going up.  The pertinent details are these; emphasis is mine:

“The recently published article included results as of July 2011. It found an increase in new prostate cancers among all three groups taking supplements, with the increase only significant in the vitamin E group. That group showed a 17 percent increase in the rate of prostate cancer compared to the placebo group.“

An unclear picture for women and supplements

The Atlantic article also discusses the Iowa Women’s Health Study, which has generated some controversy.  This study looked at the effect of taking vitamin and mineral supplements on mortality on nearly 39,000 U.S. women aged 55 to 69 and used information collected from 1986 through 2008

At the start of the study, 66% of the study subjects reported using at least one supplement. This increased to 85% in 2004, with 27 percent reporting use of four or more supplements.

The study examined the effect of taking 14 individual supplements and also a multivitamin. The researchers concluded that women who took any of six supplements or a multivitamin had a slightly higher risk of death over the study period:

• Multivitamins were associated with a 2.4 percent higher risk of earlier death
• Vitamin B6 gave a 4.1 percent higher risk
• Folic acid gave a 5.9 percent higher risk
• Iron gave a 3.9 percent higher risk
• Magnesium gave a 3.6 percent higher risk
• Zinc gave a 3 percent higher risk
• Copper gave an 18 percent higher risk
• Calcium gave a 3.8 percent lower risk of death

Do the results surprise you?  They surprised a lot of other scientists as well.  The controversy centers around the statistical methods used to analyze the data.  Though I would love to be able to explain the fine details of this issue to you, I definitely cannot do it.  (Sometimes I need a calculator to count my fingers and toes.)  Read the Atlantic article to learn more or you can hop over to the Perfect Health Diet site and see a very detailed breakdown and critique of the study.  If you scroll down just past the picture of the duckling trying to eat a fly, you’ll find it.  (The Perfect Health Diet is a pretty interesting concept.  Learn more about it here.)

One of the key elements here is that it’s an observational study, not an intervention study.  That means the researchers simply observed the subjects.  They didn’t try to change their behavior.  So while the data may seem to suggest that taking these supplements caused early death, it would be a mistake to draw that conclusion.  (One possibility is that some of the women were ill and they started taking supplements; they then died from the illness.)  The article also states, “In general, when an effect is present in some statistical models and absent in others, it means that if the effect actually exists, it’s a small one.”

A closing comment was made by Robert M. Russell, M.D., special expert to the Office of Dietary Supplements (ODS) at NIH and former senior scientist and director of the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University:

“In general, what we have learned from an accumulating database from both observational epidemiology and interventional studies is that the vitamin and minerals are safe to take in RDA amounts (as are contained in most over the counter multivitamin-multimineral preparations). Further, we have learned that taking large amounts of single nutrients or nutrient combinations often lead to chronic undesirable toxic effects with implications for chronic disease such as cancer. We have seen this with beta-carotene with a stimulation of lung cancer at high doses, and now we are seeing a similar picture with high dose vitamin E vis-a-vis prostate cancer.”

“So what is the best advice for the public? Stick to a varied diet, if you want to take supplements, take a multivitamin-multimineral that has RDA amounts. Don’t jump on the silver bullet of the day single nutrient band-wagon until there is enough evidence for both efficacy as well as long term safety. That said, in order to get RDA amounts of calcium and vitamin D, a single nutrient supplement may be necessary for some people. Following the nutrient guidance of our National Academies of Science is my best advice.”

So it seems that optimal health can be had largely by eating the right foods.  Focusing on the individual nutrients doesn’t seem wise.  There certainly doesn’t seem to be any miracle supplement out there.  The miracle is the interaction between the thousands of compounds found in our food.  If we go beyond our needs and add more of a particular nutrient then we may have trouble.

The pitchers were not injured and had no pain. But the M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. James Andrews, sports medicine orthopedist from Gulf Breeze Florida says.

Sports Medicine Said to Overuse M.R.I.s is a very valuable article from the New York Times Health section.  It deals with the widespread use and misuse of magnetic resonance imaging (MRI).  As you may know, these images can reveal all sorts of interesting information from inside our bodies.  Fractures, frayed tendons, fluid around a joint and tumors are just a few things that can we can see via an MRI scan.  The thing is, these images don’t always tell us why we’re in pain.

The quote at the top is from a study by Dr. Andrews in which he scanned the shoulders of a bunch of uninjured baseball pitchers.  Though they weren’t in pain, nearly all the scans revealed “abnormalities.”  The results are similar to a similar study of hockey players in which MRIs showed that 70% of the subjects show “abnormalities” in their hips.  The thing is none of the hockey players were injured or in pain.

The Times article discusses the profit motive behind both MRI scans:

“The price, which medical facilities are reluctant to reveal, depends on where the scan is done and what is being scanned. One academic medical center charges $1,721 for an M.R.I. of the knee to look for a torn ligament. The doctor who interprets the scan gets $244. Doctors who own their own M.R.I. machines — and many do — can pocket both fees. Insurers pay less than the charges — an average of $150 to the doctor and $960 to the facility.”

The article goes on to discuss a skier who was prescribed surgery for a torn knee ligament.  This prescription was based on an MRI and the tear was confirmed by a second opinion.  It was a third opinion and MRI however that showed that the ligament was not torn and surgery was not needed.  In this case, the third doctor noticed that the first and second assessments of the torn ligament did not match the symptoms of the man’s injury.  It seems the prior opinions relied only on what the MRI showed and not on a carefully considered history of the injury.

The overall message here is that MRIs can give us a lot of information but they may not tell us the whole story.  An MRI is not a perfect, magic tool that tells us exactly how to address our pain.  It seems the best doctors recognize this and are very careful to order MRIs only when truly needed.  Don’t be afraid to get multiple opinions on your injury.  If your doctor seems to be relying only on an MRI, keep looking around for more help.