Dr. Peter Attia & EatingAcademy.com

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A lot of recent posts on this blog have been about the high-fat/low-carb ketogenic diet. Along these lines, is the fantastic blog called the Eating Academy from Dr. Peter Attia, MD. Attia is a former surgical oncologist. He spent time at Johns Hopkins Hospital in Baltimore as well as the National Institutes of Health in the National Cancer Institute. (Go here to read more about him.)

Those are pretty impressive credentials and he’s a major reason why I’ve become convinced that much of our conventional low-fat/high-carb government-sponsored nutritional advice is bad news, and that a high-fat (including saturated fat) low-carb strategy is the ideal.

He left surgery because:

“During the fifth year of my residency I became a bit frustrated with certain aspects of medicine and health care, in general. In particular, I grew tired of the notion that we (doctors) did little to keep patients healthy, and were basically the last line of defense against, well, death, once patients become ill. The concept of “preventative medicine” received some lip service, but didn’t really have any chops as far as I could tell. In addition to this frustration (and others), I really missed quantitative and analytical problem solving.”

(I love his observation that doctors do little to prevent ill health and that they’re the last line of defense. That’s a huge issue to me. The best way to address a disease–particularly lifestyle/obesity-related illnesses like diabetes, cancer and cardiovascular disease–is to never get it. No matter how well we’re cared for, once we’re ill, we’re in trouble.)

Attia is also a fairly decent swimmer, cyclist and avid weight trainer. Thus he has an interest in nutrition not only for health but also for athletic performance. He discusses his personal nutrition journey in four parts: why he decided to lose weight, how he lost weight (ketogenic diet), how he reduced his heart disease risk, and how a low-carb diet affected his athletic performance. It’s all very detailed and very compelling.

Attia’s blog is an incredibly detailed ongoing discussion on nutrition, cholesterol, fat, weight loss, eating for athletic performance, disease avoidance, etc. He really delves into the science and some of his posts are quite a bit over my head. I love though that he discusses things like what he actually eats (here and here.) He also discusses a fascinating new sports supplement UCANN Superstarch (look here and here; I’ve been using this stuff recently and I like it A LOT.)

If any of this sounds interesting to you, go to the Start Here link and read more.

An LDL is an LDL is an LDL… Or is it?

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“We may be medicating many people who have no clear need for medication, using drugs that don’t target the right particles, and replacing foods that are benign with foods that are anything but.”

Recent posts (here and here) have dealt with the ketogenic way of eating.  So fat and all things related have been on my mind. And what terrifying substance enters our thoughts right on the heels of fat?  Cholesterol, obviously. We often think that eating more fat means more cholesterol in our bodies. (That may or may not be true and even if it is it may not be bad at all.  I know that sounds like heresy crossed with insanity but a lot of research out there strongly suggests it.) I found an interesting article recently that comes from Men’s Health by way of NBC News.

It’s called Bad cholesterol: It’s not what you think. It suggests the idea that even the so-called “bad” cholesterol isn’t all bad, and that elevated levels of a certain type of “bad” cholesterol may be no danger at all.

Most of us are fairly familiar with cholesterol.  We’re told it’s bad and that generally we should strive for a low cholesterol count. Beyond the simple cholesterol count, there is our cholesterol ratio, that is your total cholesterol count divided by your HDL count.  Most of us know about the “good” cholesterol known as HDL or high-density lipoprotein; and the “bad,” LDL aka low-density lipoprotein. We’re told that LDLs are dangerous, come from eating high-fat foods and if we have too many of them then we may need some tasty cholesterol-lowering drugs!

Well, much like characters in Game of Thrones, these LDL’s are complex and not all of them are pure evil. Here’s a description from the article (emphasis is mine.):

LDL comes in four basic forms: a big, fluffy form known as large LDL, and three increasingly dense forms known as medium, small, and very small LDL. A diet high in saturated fat mainly boosts the numbers of large-LDL particles, while a low-fat diet high in carbohydrates propagates the smaller forms. The big, fluffy particles are largely benign, while the small, dense versions keep lipid-science researchers awake at night.

So it seems we can relax a little when it comes to our view on LDLs. And we should adjust our take on what foods are truly dangerous as it pertains to cholesterol.

What often happens when we’re told we have high cholesterol or high LDLs? We’re given pills (statins) to lower our cholesterol. On that issue, the article states:

Some of these forms of LDL are relatively safe and some are dangerous, and treating them all as one and the same — the way we do every time we pay our clinic for a three-part lipid panel that simplistically says “LDL: 125” — is telling us little about the LDL cholesterol that matters, all the while sending health costs through the roof. We may be medicating many people who have no clear need for medication, using drugs that don’t target the right particles, and replacing foods that are benign with foods that are anything but.

Let’s remember that while the word “cholesterol” carries negative connotations for a lot of people, this substance actually has important physiologic functions. Our cell membranes are built from cholesterol. The myelin that wraps around our neurons and acts as a vital insulator is made of cholesterol. So cholesterol is there for a reason. (One possible impetus for increased cholesterol production in, say a hard-exercising athlete, is that tissues are being damaged from exercise and are in need of repair.  Thus we make more cholesterol to build more cells. Doesn’t sound bad does it?) So we may be stepping in the way of a not just a perfectly normal process (the manufacture of cholesterol) but a vital and healthy process that if impeded may endanger our health. I wonder if that’s why statins have so many ugly side effects.  (By the way, why do we call them “side effects?” There are only effects, right?)

Here’s some more interesting information from the article regarding HDLs vs. LDLs (emphasis is mine):

A 1977 NIH study — an early set of papers from the now legendary Framingham Heart Study — confirmed that high HDL is associated with a reduced risk of heart disease. It also confirmed that LDL and “total cholesterol” tells us little about the risk of having a heart attack, language that heart-disease authorities would downplay years later. Given this finding, as Gary Taubes writes in “Good Calories, Bad Calories,” we would have been better off to start testing for HDL — or even triglycerides — and nothing else.”

Ronald M. Krauss, M.D., the director of the department of atherosclerosis research at Children’s Hospital Oakland Research Institute, is interviewed in this article. Here makes some important observations and statements:

“Everyone doesn’t necessarily have the same amount of very small LDL in their LDL,” Dr. Krauss explains. Some people have mostly large LDL, a group Dr. Krauss would describe as “pattern A,” while others have mostly small LDL (and usually, low HDL and high triglycerides), a group Dr. Krauss would label “pattern B.” The second group has an increased risk of heart disease (a finding suggested again this year through the use of ion mobility). Large LDL, on the other hand — and large LDL is usually the majority of the LDL that shows up in a standard blood profile — is mostly benign.

The heart-disease community was not impressed. “It took me 4 years to publish that paper,” he says, recalling his early work on subparticles in the late 1970s. “That’s beginning to tell you some of the obstacles I was going to face.”

The cost of that resistance had become apparent by the mid-1980s and into the 1990s as Dr. Krauss began to test whether changes in diet could change a person’s LDL profile from good to bad, or from pattern A to pattern B. Using data from the Framingham Heart Study — the longest-running study of its kind — health organizations had begun to roll out the message of “good” and “bad” cholesterol, a message that in turn created the concept of good fats and bad fats. But during experiments, Dr. Krauss discovered that while a diet high in saturated fat from dairy products would indeed make your LDL levels rise, “saturated fat intake results in an increase of larger LDL rather than smaller LDL particles,” as he wrote in an American Journal of Clinical Nutrition review he co-authored in 2006. A diet heavy in full-fat cheese and butter — but not overloaded in calories — triggered the relatively harmless health profile described as pattern A. (Having demonstrated the benign consequences for cholesterol from consuming dairy fat, he is currently conducting studies to find out if the same holds true for diets high in saturated fat from beef.)

Did you notice those last few sentences? It’s further evidence that the high-fat/low-carb ketogenic diet is entirely safe. (Beyond just safe, there’s ample evidence of the powerful neuroprotective properties of keto diet.  It’s been used for years to treat epilepsy and may be useful in combating Alzheimer’s and Parkinson’s. I’m not sure to what degree it’s a significant component but remember, cholesterol is a key component of our neurological tissues.)

I also love this observation:

“Not only is dairy fat unlikely to increase heart-disease risk, Dr. Krauss and others have learned, but reducing saturated fat in a way that increases carbohydrates in a diet can shift a person’s LDL profile from safe to dangerous. That’s pretty much what happens whenever some well-meaning person with “high LDL” starts eating “low-fat” frozen dinners filled out with corn-derived additives, all the while engaging in the customary ravaging of a basket filled with dinner rolls.”

Here’s the big takeaway (emphasis is mine):

So with small-LDL testing far from standard (your doctor can request an ion mobility analysis from Quest Diagnostics), the surest way you can reduce your numbers of the LDL that matters is to rely on time-tested advice. Eating fewer carbohydrates, losing weight, and engaging in more physical activity have all been shown to reduce small LDL. Weight loss, in fact, has been demonstrated to reverse the dreaded pattern B all by itself. In other words, worry less about eggs or butter and their effect on LDL, and focus more on eating fewer processed foods and staying in motion. “I am very much an advocate of starting with lifestyle first,” Dr. Krauss says.”

Go here to read the full article.

Making Stuff Faster

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Here’s a very interesting video from PBS by way of Scientific American.  It’s part of the 4-part Nova series Making Stuff…  This discussion is on making stuff faster. Here, the host explores how to make faster runners.

The big takeaways here are:

  • 1) Hit the ground harder and
  • 2) Keep the torso stiff.

I haven’t seen the actual episode yet but I love the analysis and advice.  A lot of runners think that simply running more will yield better running.  But if you run the same way more and more then you should expect more of the same.  In this video, the host is given a few instructions on how to run.  The result?  He gets about 2 seconds faster on a 100m sprint.  That’s a great result!

Strength isn’t discussed in this video but I think we can very safely assume that a stronger runner can strike the ground harder than a weak runner.  So squats, deadlifts, 1-leg squats and jumping should aid in this endeavor.  Also, the advice to keep the core rigid falls right in with the research and teaching of experts like Stuart McGill.

Really, though in the end, it’s the brain that’s the target here.  The runner is able to recognize faults in his running technique and alter how he runs.  Thinking and awareness are vital!

A Ketogenic Diet Experience: the Savage Man Triathlon Double

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Guest blog post from Mike Piet

Mike Piet is a former client of mine and a very good friend. He’s also an elite-level triathlete, multiple-Ironman finisher, participant in many strange and grueling adventure races, marathons and all types of long bike excursions. We speak often of endurance activities, weight training, nutrition, and mobility and restoration work. I was very happy when he offered to write about his experience in two recent triathlons while fueling himself via the low-carb/high-fat approach. This is his tale…

Two triathlons back-to-back

On September 14-15, I participated in the SavageMan double triathlon, a tough weekend of racing in Western Maryland that includes an Olympic distance triathlon on Saturday and then a half-iron distance triathlon on Sunday.  While the Olympic is tough, it is the half- that has earned a reputation as one of the hardest races around: It features a bike course with over 6000 feet of climbing, including two uncategorized climbs.  The first of these, the Westernport Wall is 1.2 miles long with an average grade of 12% and a max grade of 31%.  Stand there long enough and you are bound to see someone literally start rolling backward.  Watch this video and you’ll get a feel for the brutal nonsense.

I have done the double two years now, but this year was different.  This year I was going to try it on a high-fat/low-carb eating protocol – I was going to use a ketogenic diet to race in a state of dietary ketosis.

I won’t get into the nuts and bolts of the ketogenic diet but in the big picture, the diet has me burning fat instead of carbs for the vast majority of the race.  This is in contrast to the typical high-carb diet favored by most endurance athletes.  The limitation of the high-carb approach is that you must continually consume bars, gels, sports drinks and all kinds of food in order to avoid running out of fuel.  This means carry lots of additional fuel and tweaking the fuel mix just right so you don’t undergo dietary distress.

For more information, I highly recommend the work of Dr. Peter Attia at the Eating Academy, Ben Greenfield, and Drs. Stephen Phinney and Jeff Volek at the Art and Science of Low-Carb.  Each of these resources explain the ideas and science behind ketosis and the ketogenic diet much better than I, but the basic premise is that in going into ketosis, your body burns fat for fuel instead of carbohydrate.  Given that fat stores are significantly (20x) larger than glycogen stores, it is a compelling experiment for long distance athletes.

A ketogenic state can’t be achieved overnight, so in the eight weeks leading up to the Savage Double, I started to change my diet over.  Approximately 70% of my daily caloric intake came from fats (olive and coconut oils, butter, heavy cream, natural peanut butter), 20% from protein and 10% from carbs.  Think Paleo or Atkins, but with dairy.  My daily carb intake was generally between 50-100 grams per day, depending on training volume, which equates to two medium bananas (48 grams), one cup of rice (45 grams), or four slices of wheat bread (52 grams).  In other words, not the typical American diet. The table below shows a typical day’s food intake. I tended to be less exacting on the weekends, but did not stray far from the guidelines:

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The numbers in the table are in grams.  As you can see, a majority was in fat – on this day I actually overshot my fat goal and was short on my carb and protein goals.  You will also notice that my sodium is high – this is a crucial aspect to doing keto right.  When carbs are minimized, the kidneys leach out sodium faster than normal, so it is important to increase sodium intake to maintain healthy blood pressures and the muscles’ electrical impulses. Going into the race, my plan was to rely on this protocol and not use my usual pre- and mid-race fueling strategies.  I was going to minimize my calories taken in, typically on the bike, because I was going to fuel my race with my own fat stores.  Going into the race, my diet remained much the same in terms of the ratios above.  On race morning both days, I had a cup of upgraded Bulletproof Coffee – a recipe borrowed shamelessly from Ben Greenfield.  One cup of coffee, 2 tablespoons each of butter and coconut oil, 4 tablespoons of heavy cream, a packet of Stevia, ¼ teaspoon of cinnamon, and a ½ teaspoon of cocoa.  I put all this in a blender until it was foamy on the top and completely mixed.  This totaled 650 calories with 72 grams of fat, 4 grams of carbs, and 1 gram of protein.  If nothing else, not sitting down to eat a meal and having all my calories contained in a cup saved a ton of time and a lot of hassle.  Thirty minutes prior to the race, I sipped a cup of chicken bouillon, with 1 gram of sodium in it.  Five minutes before the race, I used a packet of Vespa Jr., a product that helps tap into fat burning (www.vespapower.com).

Both days I carried a drink mix on the bike that was a mixture again borrowed from Ben Greenfield.  Here’s the recipe:

It calls for UCAN Superstarch, a gluten free complex carbohydrate that stabilizes blood sugar; electrolyte pills, and various other ingredients.  In short, it’s not the usual bike bottle full of sugar based energy drink.  However, on Saturday the mouth of my bottle was clogged and I couldn’t get anything out.

I rode the entire bike course without taking in any calories.

Coming off the bike I felt pretty good, so took off on the 10K run – felt good through the first aid station where I didn’t take anything, and then the second aid station.  In the interest of continuing the experiment, while I probably should have taken something at mile four, I ate nothing. I finished the Olympic tri without ingesting a single calorie since the Bulletproof Coffee in the morning, and I felt good! So good, in fact, that I was able to run a second 10K with my dad, who was also doing the race and finished the bike just as I had finished the run.  I consumed three pretzel sticks at one aid station while running with him, but otherwise water.

Results: 1st place in my age group and 12th place overall. My finishing time was 2:25 on a notoriously difficult course.

The next day was the half-iron and the protocol was the same. Same coffee, broth, Vespa pre-race.  I made sure both bottle tops were functioning because the half is such a long day.  I have only gone under 6 hours twice on this course, even though on a “normal course” my half-iron PR is 4:45.  It was a hard day right from the start and I didn’t feel like I had good legs for the ride.  I used both bottles of my drink, but no other calories – for this race, I am usually a buffet on two wheels throwing back gels, bars, and energy drinks.  Going into the run, I was not feeling good – a hard bonk was setting in and I had struggled the last 20 miles on the bike.  The first five miles of the run were mostly walk, but I came away from the low carb protocol (and you may have noticed, very little sugar), and started drinking Coke from the very first aid station.  It was all I took – no water, no food, no energy drinks.  One or two cups at each aid station – my body was craving the sugar – and interestingly, slowly, I was able to recover the back half.  The last seven miles I was able to run an honest race, something that did not seem possible when I first came off the bike.

The whole race was an incredible learning experience, and while the second day did not go as well as the first, I raced a half ironman on the heels of an Olympic (plus an extra 10K) on very few total race calories.  My recovery and refueling time on Saturday was compressed, and I think if done differently, I would have focused on that more – putting in more calories, ensuring that I stayed in ketosis, and doing more recovery and mobilization.  On Sunday, given the type of effort it is, I would have ingested more carbs earlier in the day on the bike – as Peter Defty of Vespa says, with the high fat diet, when carbs are ingested properly, they work better than if following a normal eating protocol.

Like any eating protocol, I advocate following something that works for the individual, and is sustainable.  Going keto has worked well for me. It is allowing me to go farther on much less, but may not be right for everyone.  Despite the misconception that eating a lot of fat will beget fat, I lost about 5 pounds and raced at about 165.  My body fat remained between 6-8%.

I am awaiting my blood work from Wellnessfx.com. I purchased their baseline panel and got tested prior to going keto and will be interested to see where and if the numbers have changed. I am really interested in seeing my cholesterol number.  My LDLs were a little high. The rest of my numbers were low.

Interestingly, the science suggests that contrary to medical guidelines and popular thinking, this ketogenic protocol could help lower cholesterol. I’ll post those numbers once they’re available.  For anyone interested in the hard science behind ketosis, I again recommend Drs. Phinney and Volek’s books – while technical, they provide excellent information based on science and research.

Thanks to Kyle for letting me guest post on his blog.  If anyone has specific questions about my experience and going keto, I can be reached at mdpiet@aol.com.

Stuart McGill, Born to Run & Ketogenic Eating

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Here’s what I’m into right now:

Stuart McGill

I recently finished Stuart McGill’s Ultimate Back Fitness & Performance.  It has definitely contributed to how I view conditioning and care of the spine.  For instance:

  • I’m very careful to avoid much if any bending or twisting at the lumbar spine.
  • According to McGill, the core musculature responds best to endurance-type training, so I now go for time rather than out-and-out strength.
  • McGill makes the observation that excellent athletes tend to have a very rigid core–but very mobile hips and shoulders.
  • Here are two videos with McGill.  The first has McGill discussing several myths regarding low back pain and core strength.  In the second video we see demonstrations of three exercises often prescribed by McGill.  These are often called the Big 3: the curl up, side plank and bird dog.?

Born to Run

I’m a little late to the party but I recently finished Chris McDougal’s Born to Run. This book has done more than almost anything to push the popularity of minimalist running.

Born to Run is more than a book about running.  Much of the book concerns the history and culture of the Tarahumara people who live in the isolated Copper Canyon region of Mexico.  Non-runners with any interest in other cultures will find this book very interesting.

The book and author have generated some controversy. Any runner knows about the hot debate over minimalist/barefoot-type running.  I won’t go into all that.  (For just about the most thorough discussion on minimalist running, you can’t do better than the Sports Scientists dissection of the subject.)

Here are some thoughts on both the book and discussions that have followed:

  • The story is quite entertaining.  It’s possible that the entertainment value of the book and a subsequent New York Times article from McDougal have somewhat overshadowed some facts.
  • Alex Hutchinson who writes the Sweat Science blog for runner’s world describes an interview with McDougal that clashes with later statements from McDougal.
  • Hutchinson brings up several points in his response to McDougal’s article titled The Once and Future Way to Run.  One is this:

“4. The one part of the article that made me kind of angry was this passage, about McDougall’s visit to the Copper Canyon in Mexico that led to Born to Run:

I was a broken-down, middle-aged, ex-runner when I arrived. Nine months later, I was transformed. After getting rid of my cushioned shoes and adopting the Tarahumaras’ whisper-soft stride, I was able to join them for a 50-mile race through the canyons. I haven’t lost a day of running to injury since.

I actually interviewed McDougall back in 2009, shortly before Born to Run came out. And that’s not the story he told me. Here’s what I wrote then:

Long plagued by an endless series of running injuries, he set out to remake his running form under the guidance of expert mentors, doctors and gurus. He adjusted to flimsier and flimsier shoes, learning to avoid crashing down on his heel with each stride and landing more gently on his midfoot. It was initially successful, and after nine months of blissful training, he achieved the once-unthinkable goal of completing a 50-mile race with the Tarahumara. But soon afterwards, he was felled by a persistent case of plantar fasciitis that lingered for two years. “I thought my technique was Tarahumara pure,” he recalls ruefully, “but I had regressed to my old form.” Now, having re-corrected the “errors” in his running form, he is once again running pain-free.

I’m in New York right now, and won’t be back home until Monday night, otherwise I’d see if I can dig up my actual notes from the interview. But I remember McDougall telling how stressed out he’d been, because he’d spent all this time working on a book about the “right” way to run — but as the publication date loomed ever nearer, he’d been chronically injured for two years. It was only shortly before publication that he was able to get over the injuries and start running again.”

McDougal responds to Hutchinson’s post here and Hutchinson replies back.

Personally this doesn’t do much to bother me or take away from a) a great story that’s told in Born to Run or b) the value and importance of minimalist running. I think it does suggest that McDougal is not a scientist and that the need to create a compelling story may persuade a writer to drift towards a bit of exaggeration.

What’s your take on this back-and-forth?

Ketogenic Diet (high-fat/low-carb/moderate protein intake)

Here’s another party to which I’m a bit late: the high-fat ketogenic diet.  In fact, most people who’ve tried it probably abandoned it back in the early 2000s. (I think they should’ve have.) You’ve heard of the Atkins diet.  That’s largely what I’m doing now.

In reality, I’m becoming more focused and precise with this type of eating.  I switched to a higher-fat diet when I became familiar with the Perfect Health Diet.My current efforts are informed by the Art & Science of Low-Carbohydrate Performance. Jeff Volek, PhD, RD & Stephen Phinney, MD, PhD are the authors. I like their credentials and their experience. To me, it lends weight to their words. Here’s a rundown of the main points of the book:

  • Their book is well-referenced and fairly easy to understand.
  • They present convincing evidence (to me) in favor of a) greatly reducing carbohydrate and b) greatly increasing fat intake and c) why this strategy can be very effective for athletes.
  • How?
    • Burning fat for fuel (aka ketogenesis) is a cleaner process.
    • Inflammatory stress is lower compared to using carbs for fuel
    • You’ll be less damaged from exercise and you’ll recover faster
    • You have a nearly limitless supply of fat for fuel compared to a limited supply of glycogen.
    • By shifting your metabolism to prefer fat, you’ll avoid bonking.
    • Also, by shifting your metabolism to prefer fat you’ll improve your body composition.  Besides the aesthetic appeal of a lean physique, if you’re lighter then you’ll have a better ability to produce power.  If you’re lighter then you should be able to run and bike faster.
    • Endurance athletes who experience GI distress may do very well on the high-fat diet.

I was motivated to dig into this type of eating after I spoke with my former client and friend Mike Piet.  He’s moved in the low-carb direction after his friend and accomplished ultra-distance runner  Jon Rutherford.  Jon’s experience as an athlete who’s increased his performance is described in  the Art & Science of Low-Carbohydrate Performance. Thus far, I like the results. I’ll talk more about them as this experiment continues.

Look for Mike Piet’s guest blog post as he describes his very interesting low-carb/high-fat experience during the Savage Man Olympic and half-Iron distance triathlons–done on consecutive  days.

Park-to-Park 10 Miler & The IT Band is Fixed!

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I ran the  Park-to-Park 10 Miler on Labor Day and here’s a brief rundown.  Here are the facts:

  • Time: 1:24:27.

  • 8:21/mile pace

  • 174th out of 534 participants.

  • 16th out of 44 men in my age bracket.  (I tried to calculate how I did among all men and it was hard to figure out.  Looks like I was in about the top ⅓ of the group.)

Nothing spectacular but not too terrible either.  I improved on my 2009 time by about a minute-and-a-half.  I like that.  Other than that, it was very warm and for Denver it was humid.  Denver is a hilly town.  You may not notice it if you’re driving it but try running 10 miles through town and rarely do you encounter level ground.  What follows is more important than any of this.

I first ran this race back in 2009.  That was with the beginnings of an Achilles problem that would plague me for about two years.  (And I believe the Achilles problem was a symptom of a much bigger collection of issues that had affected me since about 2002.)  Since overcoming the Achilles trouble, I’ve run several races including my first marathon last year.

This summer a new problem cropped up in the form of some knee/IT band pain.  Would this derail my race?  Discussion boards are filled with people bemoaning the fact that they’ve spent years battling IT band pain.  What did this mean for me???

I recently discussed the etiology of IT band syndrome and how to address it.  (Work on the hip abductors!!) I’ve been a religious ultra-zealot about addressing my hip abductor deficiencies. With much relief and joy, I didn’t feel a bit of pain during the run.  IT band pain often strikes during downhill descents.  I didn’t feel anything.  Nor did I notice anything near the end when I was tired and pushing hard.  I’m thrilled to have figured out this issue and to have defeated it in fairly short order.

 

Excellent Deadlift Instruction From EliteFTS

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In previous posts (which I can’t link to as my site was hacked and those posts are un-retrievable at the moment; I hope to have them available soon.) I put up some videos courtesy of Dave Tate’s EliteFTS.net  The So You Think You Can Bench Part I and Part II and Part III; and So You Think You Can Squat Parts I-V (It takes too long to copy and paste those links.  If you’re interested, go to Youtube and look them up.) series are fantastic dissections of those two lifts.

Now we’ve got So You Think You Can Deadlift Parts I-V.  This series is presented by big-time powerlifting champ Matt Wenning.  He’s a lot stronger than you, I, or anyone that we know.  He’s also maintained his health and avoided injury while competing at a high level.  This series speaks directly to using exercise to expose our weak links so we can make them stronger.  If you love to lift and you love the precise breakdown of lifting then you’ll love this series.  Here are the vids:

IT Band Syndrome: We Have A Weak Link

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“The single most important factor in predicting and possibly treating IT band problems is hip abductor strength.” John Davis, Running Writings

A weak link is found

My last post discussed finding and fixing our weak links. Well, during a trail run I found a weak link and the quest is on to bring it up to a respectable level. At this point I’ve boiled it down to poorly functioning glutes–the glute medius to be specific. Glute dysfunction is fairly common and I’m realizing more and more that I’ve had a good dose of it for quite some time. It’s gotten better but I’ve got to make it better yet. Right now this weak point is causing me some knee pain.

Inside IT band syndrome

Lateral epicondyle; where IT Band pain is typically felt

Lateral epicondyle; where IT Band pain is typically felt

Recently, while finishing a long trail run, I began to feel the dreaded symptoms of IT band syndrome (ITBS). Chances are, if you’re a runner then you either have or you will experience this issue too. If you look at the Wikipedia entry on ITBS you realize this is a mysterious ailment that might be caused by a myriad of issues from the feet to the hips, from the muscles to the bones, from too much running or cycling or rowing or dancing or whatever else you might do on one or two legs. Conventional treatment ranges from ice to ultrasound to stretching to orthotics and various pain drugs like ibuprofen.  (Do we really think that ITBS was caused by a lack of ibuprofen or an absence ice sitting on our knee?) I want to fix this issue and clarify what’s at work here. Let’s see if I can make some sense.

IT Band insertion

IT Band insertion

ITBS symptoms

The most typical symptom of ITBS is lateral knee pain, somewhere in the neighborhood of what you see on these two pictures. That’s where the IT or iliotibial band inserts. As is typical, I felt a sudden onset of pain at this site while running downhill. It’s a fairly sharp pain. Knee flexion while stepping down off a step often brings it on. Apparently, ITBS can be felt elsewhere along the IT band.

  The research: It’s all about the hip abductors.

I found some superb articles with some very valuable information regarding the root cause(s) of ITBS and how to address the issue. Biomechanical solutions for iliotibial band (IT band) syndrome / ITBS comes from RunningWritings.com.  Glutes rehab – recent research and Gluteus medius – evidence based rehab come from Running-physio.com. There is some overlap between these articles and they all refer to quite a bit of important research.  If you’re a trainer who’s working with someone who has ITBS or if you’re suffering from ITBS, I strongly suggest you read these articles. I’ve summarized some things but definitely go to the sources for a thorough rundown.

Both sources cite a study from Stanford, and here’s what you need to know:

“Long-distance runners with ITBS have weaker hip abduction strength in the affected leg compared with their unaffected leg and unaffected long-distance runners. Additionally, symptom improvement with a successful return to the pre-injury training program parallels improvement in hip abductor strength.”

Some sources suggest that foot/ankle dysfunction–specifically over-pronation–is at the cause of ITBS rather than hip dysfunction. Irene Davis and others of the University of Delaware studied both the hips and feet/ankles. They stated:

“However, aside from this variable [an increase in rearfoot inversion moment], these results begin to suggest that lower extremity gait mechanics [i.e. foot and ankle] do not change as a result of ITBS. Moreover, the similar results of the current study […] suggest that the aetiology of ITBS is more related to atypical hip and knee mechanics as compared to foot mechanics. Therefore, the current retrospective study provides further evidence linking atypical lower extremity kinematics and ITBS. (Ferber et al.)”

The Running Writings article discusses several other studies that had similar findings to the Stanford study. The writer reached this conclusion:

“At this point, the evidence overwhelmingly points to a biomechanical fault in the abductor muscles of the hip as the root cause for IT band syndrome.  Weak or misfiring gluteus medius, gluteus minimus, or tensor fasciae latae muscles are unable to control the adduction of the hip and internal rotation of the knee, leading to abnormal stress and compression on the IT band.  This muscular dysfunction manifests as excessive hip adduction and knee internal rotation, both of which increase strain on the iliotibial band and compress it against the fatty tissue between the lateral femoral epicondyle and the IT band proper, causing abnormal stress and damage. But although the pain is coming from the lateral knee, the root of the problem is coming from the hip muscles.”

(By the way, the hip abductors of which I speak consist of the gluteus maximus, gluteus medius, gluteus minimus and the tensor fascia latae or TFL.  See below.

Here’s something important: Very often the glute medius doesn’t do its share of the work and the TFL does too much work. Therefore it becomes important to condition the glute medius while de-emphasizing TFL activity. The side-lying hip abduction exercise (described below) works particularly well for activating the glute med while minimizing TFL activation.)

Hip abductors. If they're weak, your knees will probably hurt.

Hip abductors. If they’re weak, your knees will probably hurt.

The Running Writings piece also says, “a doctoral thesis by Alison Brown at Temple University also investigated (hip abductor) muscle strength in runners with and without ITBS; interestingly, she found no difference in maximal strength, but a significant difference in endurance.”

On a slightly different note, a recent study in Medicine and Science in Sports and Exercise indicates excessive hip adduction (adduction is the opposite of abduction; If you adduct too much then you’re not abducting enough.) is a precursor to patellofemoral pain or PFP. So again, we see abnormal hip mechanics playing a role in knee pain in runners.

Finally, the Running Writings article does a nice job of dispelling some myths about ITBS, among them the idea of foam rolling and/or stretching the IT Band. I won’t go into all of it but the bottom line is: Don’t bother. The IT band isn’t the problem–it’s the hip abductors! Work on them.

Tredelenburg gait

What happens when those hip abductors fail to do their job? We get what’s called Trendelenburg gait. Here’s a picture of it.  Notice the right

Trendelenburg gait

Trendelenburg gait

hip drops. When that happens the hip muscles on the left are stretched which puts prolonged tension on the IT band. That excess tension may cause pain at the IT band insertion located on the knee. There’s your pain.

Testing the abuductors

Heeding the observation that hip abductor endurance is key to ITBS, I tested that endurance using the old-fashioned, Jane Fonda-style side-lying hip abduction. (I elected to forgo leg warmers.) I got to almost 30 reps on my right leg (the affected side) and the hip was dying. I got to 30 reps on the left leg and with only moderate fatigue. I’ve seen similar performances in several other clients and my wife who also has some ITBS. This all fits in line with what this research found.

The exercises

The two articles from RunningPhysio do a great job of discussing a wide variety of exercises that engage the glutes. In Glutes rehab: recent research we see research on the exercises that elicit the most contraction from both glute medius and glute max. Look at the tables below to see which exercises get the most out of these muscles. (I’m not sure exactly how all of these exercises were performed.)

wpid-Photo-5-Nov-2012-1944 wpid-Photo-5-Nov-2012-2022

 

 

 

 

Here’s RuningPhysio’s take on how to apply this information:

Practical application

From the research findings a good programme for runners wanting to target GMed would be starting with single leg mini-squat, side-lying abduction and pelvic drops and progressing to single leg dead lift, single leg squat and side-lying bridge to neutral. For advanced work you could add leg weight to side-lying abduction or combine side plank with upper leg abduction. This set of exercises would start with at least moderate GMed activation and progress to in excess of 70% MVIC. It would contain both functional weight-bearing exercises that are a closer fit to the activity of running, and non-weight bearing activities like side-lying abduction which has been shown to activate GMed without increasing unwanted activity in TFL and anterior hip flexors (McBeth et al. 2012) and has been used successfully to rehab runners with ITBS (Fredericson et al. 2000).

Runners wanting to improve GMax could start with single leg bridge, lunge with neutral trunk and single leg mini-squat and progress to single leg squat, single leg dead lift and forward step up. All of these exercises are ‘closed chain’ single leg activities where the GMax provides power to extend the hip but also works to help stabilise the hip and pelvis. As a result they are fairly functional for runners as GMax has a similar role during running.

In Gluteus Medius: Evidence-based rehab, the writer very wisely discusses differences in what we might call “functional” vs “non-functional” exercises. (This article also describes most of the exercises you’ll want to employ.) Generally, we might say a functional exercise would look like something we do in real life. A 1-leg squat or 1-leg deadlift is an example. These exercises have us standing (weight bearing) and using the whole body in concert. We don’t isolate a muscle in a functional exercise but rather we train a movement pattern and integrate lots of muscles together. In contrast, a non-functional exercise tends to isolate a muscle. The side-lying abduction or side plank are examples of non-functional exercises. These exercises don’t much resemble anything we do during most of our daily activities or sports. That doesn’t mean they don’t have value though, and the article does a nice job of discussing this issue.  The article states:

“Closing thought, from the research I’ve read and patients I’ve seen, a combination of both functional weight bearing and less functional (sidelying) exercises is most likely to be effective in glutes rehab.”

My process

Like I said, my right glute med is indeed easier to exhaust than my left. I figure though that I should work both sides with a little extra work on the right. I’ve been doing lots of the side leg raises and side planks.  I can’t yet do a good side plank while abducting the top leg. That’s a tough one. It’s one to shoot for in the future. I’m also doing a lot of band walks.  I don’t loop the band around my ankles though, I loop it around my feet. This study determined that placing the band around the feet recruits more glutes and less TFL. These are sort of the non-functional exercises that I do pre-workout or first thing in the morning.  

Pre-workout or throughout the day:

  • side-lying hip abduction: 2-3 sets x 10-20 reps.  I go to exertion.
  • side planks: 2-3 sets x 10-20 seconds
  • band walks: I side shuffle as well as walk forwards and backwards. I go to exertion.
  • Hip hikes: Easy to do. This movement has you lifting the pelvis away from the Trendelenburg gait pattern.

Functional/main exercises:

  • 1-leg squat: 3 x 8-15 reps. I recently used a kettlebell in the arm opposite my stance leg.  I focus on keeping my pelvis level, knees somewhat apart and I don’t let my non-stance side hip drop which is very important. I also throw several reps in randomly throughout the day.

  • 1-leg deadlift 3 x 8-15 reps: I often hold one or two kettlebells, dumbbells or a barbell.

  • Off-set step up: 3 x 6-12 reps use a knee-high plyo box for this. I hold a dumbbell on the side opposite my stance leg. I drive up powerfully with the stance leg then do my best to control my descent back down. I don’t plummet back down uncontrolled.

  • ice skaters: 3 x 12-20 reps. This is a power exercise in which I drive side to side in an explosive manner. There’s no way to do this without using the glute medius.

  • 1-arm carries/farmer walks: I carry a kettlebell in one hand and walk. Very functional and simple to do.

These exercises do a great job of conditioning our movement sling system. Read here and here to learn more about these systems of muscles that work together as we move.

Using Exercise to Expose Weakness: Part I

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weak linkA general sort of concept is on my mind and it’s been expressed by several experts that I look up to. In his book Movement, Gray Cook says “True champions will spend more time bringing up weaknesses than demonstrating strength.” The great powerlifting coach Louie Simmons of Westside Barbell says, “The Westside program is all about finding where you are weak and making it strong.” Your weaknesses will hold you back.” Kelly Starrett discusses the idea of “making the invisible visible.” With this statement he suggests we can use exercise to expose movement problems. (He talks about this concept here,here and here.)  What does all this mean?

All these guys are telling us that rather than going to the gym and doing fun stuff that we’re already good at and simply making our strengths stronger (taking the easy route, really) rather we should find our weaknesses and work like hell to bring them up to speed.

A slightly different paradigm

I think most of us have an equation in our head regarding exercise.  It might look like this:

I exercise → I get stronger.

(BTW, the word “strong” doesn’t just mean muscular strength.  We can get stronger at swimming, biking, driving a golf ball, carrying bags of mulch, etc. “Stronger” means to improve an ability.)

There might be a few more dots to connect between those statements though. With regard to the earlier statements about weaknesses and making the invisible visible (i.e. make hidden weaknesses visible), we might see the equation thus:

I exercise → I expose weaknesses/pain/poor movement → I correct/improve my weaknesses and poor movement →I get stronger.

What often happens is that we find an exercise that we enjoy doing and at which we’re very strong. We really like that exercise! We do it and we demonstrate to ourselves (and let’s face it, others in the gym) how strong and able we are. Therefore our already well-developed ability gets stronger.

In contrast, I think a lot of us have discovered exercises that we don’t like. The movement pattern feels awkward, painful or somehow asymmetrical or unbalanced. We have a poor ability to execute the exercise. We may tack it on at the end of a workout if we feel like it–and we rarely feel like it. In other words, we’re weak at this particular movement. We don’t do it well and we know it so we avoid it. Thus we rarely if ever explore this particular exercise. What happens?  We probably get weaker and weaker at it.

So while something we’re already fairly good at gets better, a glaring weakness gets weaker.  And what do we know about chains and weak links? At some point that weak link (poor movement pattern) is going to cause us a problem if it isn’t already. We may not even know how strong we could be if we fixed our weakness.

My rule of thumb is: “If it’s really difficult to do and you don’t like doing it, then you probably need to do a whole lot of it.”

My experience

A lot of my clients have movement problems and various aches and pains. Their weaknesses are often rooted in a forgotten ability to move properly and maintain their joints in proper position. We frequently need to dial back the exercise intensity and simply work on slow, proper, mindful movement. Sometimes this requires a frustrating level of concentration. It gets difficult. It isn’t always fun. This frustration may lead a client to say ” I just want to work out!  I don’t want to think!” In other words, he or she want to revert to their hold habits, ignore their movement shortcomings and do what they’re already good at.

This is an important fork in the road. If a client chooses to continue to focus and do the hard work of correcting bad habits–to improve their true weaknesses–then he or she will almost certainly start to see lasting improvement in the near future. This client and I will likely have a long, productive and happy relationship. On the other hand, we have another type of client.  He or she balks at the first sign of difficulty, ignores and avoids weaknesses, and in essence chooses to tread water and only marginally strengthen their limited strengths.  He or she has picked an easy but limited route. In this case, our relationship is thankfully short.

The big picture

I’m going to go into some specifics in the next post, but for now I’d like you to consider the idea that the real way to get stronger is to seek out and wallow in your pathetic weaknesses. If you think you don’t have any, then add weight, reps, range of motion and/or speed to see if things start to come apart. Recognize where you start to fail and dedicate yourself to working on those weaknesses.

Where’s Your Weak Link? Using Exercise to Expose Weakness – Part I

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Where's your weak link?

One big concept is on my mind and it’s been expressed by several experts that I look up to. In his book Movement, Gray Cook says “True champions will spend more time bringing up weaknesses than demonstrating strength.” The great powerlifting coach Louie Simmons of Westside Barbell says, “The Westside program is all about finding where you are weak and making it strong. Your weaknesses will hold you back. Kelly Starrett discusses the idea of “making the invisible visible.” With this statement he suggests we can use exercise to expose movement problems. (He talks about this concept here, here and here.)  What does all this mean?

All these guys are telling us that rather than going to the gym and doing fun stuff that we’re already good at and simply making our strengths stronger (taking the easy route, really) rather we should find our weaknesses and work like hell to bring them up to speed.

A slightly different paradigm

I think most of us have an equation in our head regarding exercise.  It might look like this:

I exercise → I get stronger.

(BTW, the word “strong” doesn’t just mean muscular strength.  We can get stronger at swimming, biking, driving a golf ball, carrying bags of mulch, etc. “Stronger” means to improve an ability.)

There might be a few more dots to connect between those statements though. With regard to the earlier statements about weaknesses and making the invisible visible (i.e. make hidden weaknesses visible), we might see the equation thus:

I exercise → I expose weaknesses/pain/poor movement → I correct/improve my weaknesses and poor movement →I get stronger.

What often happens is that we find an exercise that we really like and at which we’re very strong.  We really like that exercise! We do it and we demonstrate to ourselves (and let’s face it, others in the gym) how strong and able we are. Therefore our already well-developed ability gets stronger.

In contrast, I think a lot of us have discovered exercises that we really don’t like. The movement pattern feels awkward, painful or somehow asymmetrical or unbalanced. We have a poor ability to execute the exercise.  In other words, we’re weak at this particular movement.  We don’t do it well and we know it. Thus we rarely if ever explore this particular exercise.  What happens?  We probably get weaker and weaker at it.

So while something we’re already fairly good at gets better, a glaring weakness gets weaker.  And what do we know about chains and weak links? At some point that weak link (poor movement pattern) is going to cause us a problem if it isn’t already. We may not even know how strong we could be if we fixed our weakness.

My rule of thumb is: “If it’s really difficult to do and you don’t like doing it, then you probably need to do a whole lot of it.”

My experience

A lot of my clients have movement problems and various aches and pains. Their weaknesses are often rooted in a forgotten ability to move properly and maintain their joints in proper position. We frequently need to dial back the exercise intensity and simply work on slow, proper, mindful movement. Sometimes this requires a frustrating level of concentration. It gets difficult. It isn’t always fun. This frustration may lead a client to say ” I just want to work out!  I don’t want to think!” In other words, he or she want to revert to their hold habits, ignore their movement shortcomings and do what they’re already good at.

This is an important fork in the road. If a client chooses to continue to focus and do the hard work of correcting bad habits–to improve their true weaknesses–then he or she will almost certainly start to see lasting improvement in the near future. This client and I will likely have a long, productive and happy relationship. On the other hand, we have another type of client.  He or she balks at the first sign of difficulty, ignores and avoids weaknesses, and in essence chooses to tread water and only marginally strengthen their limited strengths.  He or she has picked an easy but limited route. In this case, our relationship is thankfully short.

The big picture

I’m going to go into some specifics in the next post, but for now I’d like you to consider the idea that the real way to get stronger is to seek out and wallow in your pathetic weaknesses. If you think you don’t have any, then add weight, reps, range of motion and/or speed to see if things start to come apart. Recognize where you start to fail and dedicate yourself to working on those weaknesses.