Athletes
Sports Spine Specialist Chiropractic Team: Athletes strive to achieve their body’s maximum performance by participating in numerous training regimens consisting of strenuous exercises and physical activity and ensuring they meet all of their body’s nutritional requirements. Through proper fitness and nutrition, many individuals can condition themselves to excel in their specific sport. Our training programs are designed for athletes that look to gain a competitive edge in their sport.
We provide sport-specific services to help increase an athlete’s performance through mobility, strength, and endurance. Occasionally, however, the excess workouts can lead many to suffer injuries or develop underlying conditions. Dr. Alex Jimenez’s chronicle of articles for athletes displays in detail the many forms of complications affecting these professionals while focusing on the possible solutions and treatments to follow to achieve overall well-being.
by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Athletes, Complex Injuries, Physical Rehabilitation, PUSH-as-Rx
Chiropractor, Dr. Alexander Jimenez looks at the way this common injury shows itself.
Introduction
Iliotibial band syndrome (ITBS) between the knee is frequently diagnosed in sport injury clinics. ITBS presents having an incidence rate of around 22% in most lower extremity running-related injuries (1) also has been said to be the second most common complaint amongst distance runners (2). ITBS has been given the expression ‘runner’s knee’.
Trainers like endurance runners who perform flexion and extension combined with loading are subjected to this illness. ITBS presents during the first two or three miles in running with no mechanism of injury, which can make identifying the cause more interesting. With plenty of factors having been considered within the literature, changes are often purported to be a cause of ITBS. But some biomechanical factors have been researched and have been found to have little or no effect in the start of ITBS. Therefore this text’s point would be to examine the biomechanical changes which may induce an individual to the beginning of ITBS. The research published reviewed is largely based on a current systematic review that was published in Physical Therapy in Sport in 2014 (3).
Anatomy & Function
The iliotibial band (ITB) encapsulates the tensor fascia latae (TFL) presenting with both deep and superficial fibre attachments at the pelvis (4). In addition to attaching to the TFL, approximately three-quarters of the gluteus maximus tendon also conjoins with the ITB (4). The ITB courses along the lateral aspect of the hip and passes the greater trochanter. The ITB maintains an attachment on the posterior ridge of the femur whilst attaching itself to the fascia. The ITB has a fixed attachment at the lateral femoral condyle where it then divides into three segments with the first being the lateral patella (3). The remaining two segments cross the knee joint to insert at the head of fibula and most distally at the infrapatellar tubercle also known as Gerdy’s tubercle on the tibia (3). Figure 1 illustrates the location of the ITB.
The ITB passively functions to resist hip adduction, hip internal rotation and internal rotation of the knee in accordance with its attachments at the pelvis, femur and tibia(3). The gluteus maximus functions, through its attachment, to increase stability through the hip and knee complex by increasing the tension of the ITB(4). It is possible to see, based on its attachments at both the knee and hip, how changes could bring about the onset of ITBS.
Studies have proposed that as the knee flexes and extends the ITB ‘slides or flicks’ over the lateral femoral condyle of the knee causing an irritation beneath. This notion was debated by Falvey and colleagues (5), who stated that it was highly unlikely that the ITB would flick or slide over the bone during knee flexion due to it not being a loose structure. But the authors did agree that the impact of compression on the richly innervated fat pad was pain’s cause but by strain of the ITB where pain presents crossing the lateral femoral condyle. Strain rate and strain magnitude were measured in a prospective study involving female runners (6). The results indicated that frequency of strain of the ITB at the lateral femoral condyle was greater that the strain magnitude. This implies that a runner might have the ability to run for a short period but then incur lateral knee pain because of the strain to the ITB.
MRI scans have ascertained the knee flexion angle of 30� elicited the greatest compression of the ITB at the point of heel strike, whereas others have said that maximal compression occurs between 20-30�(2,6). A knee flexion angle at the point of heel strike has been found to be significantly different with 20.6� in ITBS patients compared to 15.3� in the control(7). Downhill running produces a greater knee flexion angle at the point of heel strike eliciting a larger strain load to the ITB and therefore this is often a main precursor to ITBS (6). Although an elevated knee flexion angle at the point of heel strike has been considered to contribute to ITBS, it is essential to examine the lower extremity from the frontal and transverse planes too and not solely from the sagittal plane (2).
Rearfoot Eversion
It’s possible to envisage how rear foot eversion could contribute to ITBS causing internal rotation of the tibia resulting at the distal attachment in greater strain of the ITB. In contrast Ferber and colleagues (2) indicated that there was no significant difference in the peak eversion angle of the female subjects, who were previously diagnosed with ITBS but were now symptom free, compared to controls. In a similar study non-significant differences were found between the currently symptomatic ITBS patients and controls for rear foot eversion (8).
Louw & Deary(3) found that ITBS patients sometimes demonstrated decreased eversion angles, accompanied by decreased internal rotation of the knee, at the point of heel strike. Ferber and colleagues (2) noted an increased inversion moment in the ITBS group which was suggested to control and limit the eversion moment. By comparison, currently symptomatic ITBS patients demonstrated a substantial difference compared to a control group with twice the rear foot motion during running (9).
Knee Internal Rotation
Peak internal rotation angle of the knee was found to be significantly greater in the ITBS patients when compared with controls at the point of heel strike (2). This research was supported by other studies who also found a significant effect for increased internal rotation of the knee following a run of moderate intensity to physical exhaustion(7). With excessive rotation comes compression due to increased strain of the ITB at the attachment.
An explanation of increased internal rotation of the knee was attributed to excessive external rotation of the femur perhaps due to shortening of the piriformis, gemellus inferior and superior and the obutrator externus (8). The authors added that excessive rotation at the hip might result from muscular activity of the rotators that were hip being the medius, minimus and the tensor fascia latae. These studies(2,7) were retrospective in design in that they tested healthy runners with a history of ITB pain, whereas(8) was a prospective study of patients with ITBS at the point of testing.
Hip Adduction Angle & Hip Abductor Strength
The hip adduction angle during the stance phase has been suggested to be greater. Ferber and colleagues(2) found that the peak hip adduction angle was significantly greater in the ITBS cohort and stated that with 95% confidence. Increased angle results in increased stress to the ITB and consequently increased compression at the lateral femoral condyle when combined with increased internal rotation of the tibia.
Figure 2 illustrates, when peak hip adduction and internal rotation combine, how this may result in increased the compression of the ITB at the lateral femoral condyle. Louw and Deary(3), however, stated that it remained inconclusive whether the peak hip adduction angle was a substantial element. Additional research is therefore required to support Ferber and colleagues'(2) initial findings as this study was a retrospective study carried out on healthy female runners with a history of ITBS.
Hip Abductor Strength
It’s been proposed that an increased peak hip adduction angle may coincide with hip abductor activity involving the gluteus medius in this group. During the stance phase of gait the gluteus medius functions to keep stability. Research has indicated that during stance the adduction forces can exceed three times an individual’s body weight(3). What’s more, it was stated that these forces were beyond the metabolic capacity of the gluteus medius to main pelvic stability during the stance phase using just this muscle alone(3).
Louw and Deary (3) were not able to identify a heightened hip abductor moment in the ITBS patients with increased peak hip adductor angles and suggested that it was more of an issue of timing as opposed to the size of the hip abductors. Louw and Deary (3) stated that the research is yet to examine trunk and pelvic movements in ITBS patients and it is plausible to suggest that biomechanical changes from higher up the kinetic chain has the potential to be a contributing element in ITBS etiology.
A research study of 24 (14 female, 10 male) patients with ITBS undertook a six-week rehabilitation programme to increase the strength of the hip abductors(10). Following six weeks of hip abductor strengthening to running 22 patients reported being pain-free and had returned. The female patients reported an average hip abductor torque increase of 34.9% and the male patients found 51.4% increase. However this study used a hand held dynamometer to measure isometric strength and therefore Fedricson (10) findings should be viewed with caution.
A more recent study assessed the hip abductor strength of currently symptomatic patients with healthy controls in a fixed position(11). The results indicated that no substantial differences occurred for static and dynamic hip abductor strength between the groups. Further research should look into the EMG and strength of the hip abductors in the role of managing ITBS. Table 1 shows of significance in the some of the variables of the studies used in this text.
Rehabilitation programs, following periods of immobilization and during, should include gluteal exercises to provide stability to the leg that is involved. If active exercises for the gluteal muscles are provided in a manner that is secure and effective then this can influence the period of transition from non weight. It’s prudent based on the research provided to date to develop function although research is lacking in terms of quality and volume as to the biomechanical influences on the etiology of ITBS. This guarantees that once load bearing commences that the leg that is involved has the stability and control that is active to keep the beginning of load of the ITB.
Summary
The recent review published by Louw and Deary(3) indicates that much of the research published within the literature depending on the etiology of ITBS is inconclusive. The level of research is relatively low and is based on retrospective trials. The research does indicate that knee biomechanics and abnormal hip is involved in the occurrence of ITBS. The authors ascertain that muscle strength is involved as is foot biomechanics that are abnormal. It is recommended that future research should measure kinematic movements of the hip and knee during downhill running as this is a complaint of ITBS onset.
References
1.Clini J of Sports Med, May 2006,16, (3), 261-268
2.J of Sports Phys Therap, Feb, 2010, 40, 2, 52-58.
3.Phys Therap in Sport, 2014, 15, 64 e75.
4.Surgic and Radiologic Anatomy (Dec) 2004; 26, (6), 433 – 446
5.Scand J of Med & Sci in Sports, Aug 2010, 20 (4), 580-587.
6.Clini Biomech, 2008, 23, 1018-1025.
7.Gait Posture. 2007 Sep, 26 (3), 407-13
8.Clini Biomech, Nov 2007, 22 (9), 951-956.
9.Med Sci in Sport & Ex, 1995, 27, 951-960.
10.Clini J of Sports Med, 2000, 10:169�175.
11. Int J of Sports Med, Jul, 2008, 29 (7), 579-583.
by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Diets, Fitness
Macaroni and cheese mixes made with powdered cheese contain high levels of potentially harmful chemicals called phthalates, according to a new study.
Phthalates, which can get into food from packaging and equipment used in manufacturing, have been linked to genital birth defects in infant boys and learning and behavior problems in older children, The New York Times reported.
Researchers tested different cheese products and found that all 10 varieties of macaroni and cheese included in the study had high levels of phthalates, even those labeled as organic.
“The phthalate concentrations in powder from mac and cheese mixes were more than four times higher than in block cheese and other natural cheeses like shredded cheese, string cheese and cottage cheese,” said Mike Belliveau, executive director of the Environmental Health Strategy Center, one of four advocacy groups that funded the report, according to The Times.
The other groups were the Ecology Center, Healthy Babies Bright Futures and Safer States.
“Our belief is that (phthalates are) in every mac ‘n’ cheese product – you can’t shop your way out of the problem,” Belliveau said.
He encouraged consumers to contact manufacturers and ask them to determine how phthalates are getting into their products and take action to prevent it. Nine of the cheese products tested were made by Kraft. Company officials did not respond to requests for comment on the study findings, The Times reported.
The U.S. government phthalates from children’s teething rings and rubber duck toys a decade ago.
by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Diets, Fitness, Pregnancy
Pregnant women who drink non-diet sodas during pregnancy are more likely to have kids who carry extra body fat by age 7, researchers say.
In the study of more than 1,000 mother-child pairs, each additional serving of sugary soda per day consumed in pregnancy was associated with higher increments of waist size and body mass in kids years later.
“Sugary beverages have been linked to obesity in children and adults,” said study author Sheryl Rifas-Shiman of Harvard Medical School in Boston.
Although past research has tied sodas and some fruit drinks to excess weight gain, obesity, metabolic syndrome and type 2 diabetes, few have looked at beverage intake during pregnancy, she and her colleagues write in Pediatrics.
“Childhood obesity is widespread and hard to treat,” Rifas-Shiman told Reuters Health by email. “So it’s important to identify modifiable factors that occur prenatally and during infancy so prevention can start early.”
The researchers recruited 1,078 women from among patients at eight obstetric offices affiliated with Atrius Harvard Vanguard Medical Associates in eastern Massachusetts.
The study team had in-person meetings with each woman at the end of her first and second trimesters, as well as during the first few months after her baby was born. In addition, kids were assessed in early childhood, around age 3, and in mid-childhood, around age 8. Mothers also completed mailed questionnaires every year for the child’s first six birthdays.
At all visits, researchers collected information about both parents and details of the household. During pregnancy, women answered questionnaires about what they typically ate and drank, including how much regular and sugar-free soda, fruit juice, fruit drinks and water they consumed each day.
At the mid-childhood visit, when kids were between ages 6 and 11 years, the research team measured each child’s height, weight, waist circumference and skinfold thickness. With these measurements, they calculated body fat percentage and body mass index (BMI), a measure of weight relative to height.
When researchers looked at data gathered during pregnancy, they found that more than half of mothers had consumed more than half a serving a day of non-diet soda during pregnancy, and nearly 10 percent had consumed two or more servings a day.
Mothers who drank more sugary drinks during pregnancy tended to be younger, had higher prepregnancy BMI, lower education, lower income, shorter breastfeeding times and were more likely to have smoked during pregnancy.
About one quarter of the children were overweight or obese by mid-childhood, and BMI, waist circumference and skinfold thickness were highest among kids whose mothers drank at least two servings of sugary drinks per day.
Only regular sodas were associated with this difference. Juice, diet soda and water consumed during pregnancy weren’t linked to a higher BMI score in kids. The research team also didn’t see differences based on the mother’s weight, race or ethnicity, the child’s gender or the amount of soda children themselves drank.
“I was surprised that maternal intake seemed to be more important than child intake,” Rifas-Shiman noted.
In the future, she and colleagues plan to study the long-term effects of efforts to reduce sugary beverage intake during pregnancy. They’re now using new methods to analyze when children’s intake of sugary beverages matters the most for their weight and health.
“I was struck that the differences in children’s body composition were seen in relation to intake levels that appear unremarkable, even less than one serving per day,” said Sian Robinson of the University of Southampton in the UK, who wasn’t involved in the study.
“We need to know more about the long-term effects of maternal nutrition on offspring health,” she told Reuters Health by email. “Few intervention studies in pregnancy have longer-term follow-up data to describe the effects on children’s body composition.”
Several of these intervention studies have been completed recently, Robinson added, and that follow-up data will be available soon.
“The links between sugar-sweetened beverages and obesity are well-established,” she said. “But this new data suggests mothers’ consumption is important and has public health relevance.”
by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Diets, Fitness
It’s hard to eat right all the time, but making small improvements by choosing healthier foods now and then may significantly boost one’s chances of living longer, said a US study Wednesday.
The report in the New England Journal of Medicine is the first to show that improving diet quality over at least a dozen years is associated with lower total and cardiovascular mortality.
Researchers at Harvard University tracked dietary changes in a population of nearly 74,000 health professionals who logged their eating habits every four years.
Researchers used a system of diet-quality scores to assess how much diets had improved.
For instance, a 20-percentile increase in scores could “be achieved by swapping out just one serving of red or processed meat for one daily serving of nuts or legumes,” said a summary of the research.
Over the 12-year span, those who ate a little better than they did at the start — primarily by consuming more whole grains, fruits, vegetables, and fatty fish — saw an eight to 17 percent lower risk of dying prematurely in the next 12 years.
Those whose diets got worse over time saw a higher risk of dying in the next 12 years of follow-up, on the order of a six to 12 percent increase.
“Our results highlight the long-term health benefits of improving diet quality with an emphasis on overall dietary patterns rather than on individual foods or nutrients,” said senior author Frank Hu, professor and chair of the Harvard Chan School Department of Nutrition.
“A healthy eating pattern can be adopted according to individuals’ food and cultural preferences and health conditions,” he added.
“There is no one-size-fits-all diet.”
by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Diets, Fitness
The U.S. is one of the world’s laziest countries, according to a new Stanford University study that used smartphone measurements of the number of steps taken by people in 46 countries.
The study, published in the journal Nature, included 700,000 participants and was “1,000 times larger than any previous study on human movement,” co-leader and Stanford bioengineering professor Scott Delp said, the BBC reported.
Countries with the highest average number of steps walked included China, Ukraine, Japan, and No. 1 Hong Kong, with 6,880 steps walked per day on average, USA Today reported.
The U.S. ranked in the bottom half of countries represented, with 4,774 steps walked per day, just below the worldwide average of 4,961 steps. Indonesia had the least steps walked with 3,513 per day on average, USA Today reported.
The study found that countries where people walked a similar amount of steps each day had lower rates of obesity, whereas countries where some people walked a lot and others walked very little had higher rates of obesity. The U.S. falls into the latter category, with high levels of what the study called “activity inequality.”
The study analyzed a total of 68 million days’ worth of data and tracks people’s activity over longer periods of time than previous studies, the BBC said.
Women averaged about 1,000 fewer steps than men in the U.S., and suburban areas reported fewer steps on average than urban, city areas that are more pedestrian-friendly.
Researchers hope the data might help design towns, cities, and neighborhoods that encourage more physical activity.
by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Diets, Fitness
Western diets, high in sugar and fat, cause liver inflammation, especially in males, according to a new animal study in The American Journal of Pathology. Inflammation was most pronounced in males that lacked farnesoid x receptor (FXR), a bile acid receptor.
The study also found that probiotics may prevent and treat the condition, keeping it from advancing to liver cancer.
“We know the transition from steatosis, or fatty liver, to steatohepatitis — inflammation in the fatty liver — plays a crucial role in liver injury and carcinogenesis,” said lead investigator Yu-Jui Yvonne Wan, Ph.D., Professor and Vice Chair of the Department of Pathology and Laboratory Medicine at UC Davis Health.
“Because the liver receives 70 percent of its blood supply from the intestine, it is important to understand how the gut contributes to liver disease development,” Wan said.
“Our data show that diet, gender, and different antibiotic treatments alter the gut microbiota as well as bile acid profile and have different effects on liver inflammation,” she said.
Wan used an FXR-deficient mouse model (FXR KO), which has become an important tool to better understand the role of diet and inflammation in the development of liver diseases, including cancer, because patients with cirrhosis or liver cancer also have low FXR levels.
Other studies have found that mice deficient in FXR spontaneously develop liver problems and tumors even when they are fed a normal diet.
In this study, FXR-deficient mice as well as wild mice were fed either a Western diet or a matching control diet for 10 months. Both Western diet-fed wild-type mice and control diet-fed FXR KO mice accumulated fat in the liver, which was more severe in males than females.
The study suggested that antibiotics might help block inflammation in control mice, but not in the FXR KO mice fed a Western diet. It also indicated that probiotics might also deter some of the inflammation.
“Our results suggest that probiotics and FXR agonists hold promise for the prevention and treatment of hepatic inflammation and progression into advanced liver diseases such as cancer,” Wan said.
A recent Australian study found that zinc may be a major key in fighting liver damage. An article published in Nature Communications found that zinc had the potential to be a simple and effective treatment against acute and chronic liver inflammation.
Other natural substances have been found to be effective against liver disease. A 2016 study conducted at the University of Southampton found that two cups of coffee a day reduced the risk of liver cirrhosis — scarring due to alcohol and viruses like hepatitis C — by 44 percent.
by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Diets, Fitness
Australian researchers have found that exercising as a child could potentially counteract the damage of a high-fat diet later in life.
Carried out by a team from the Liggins Institute at the University of Auckland, the animal study looked at the effect of different diets and exercise programs on rats’ bone health and metabolism, focusing on the activity of the genes in bone marrow.
Rats were given either a high-fat diet and a wheel for extra exercise, a high-fat diet but no wheel, or a regular diet and no wheel.
High-fat diets in childhood are known to “turn up,” or increase, the activity of other genes that cause inflammation — the body’s natural self-protective response to acute infection or injury. Ongoing inflammation as a result of high-fat diets can damage cells and tissues, increasing the risk of obesity, heart disease, cancer among other conditions.
However, the team found that in the rats given a high-fat diet and an exercise wheel, the early extra physical activity caused inflammation-linked genes to be turned down, not turned up.
It appeared that exercise altered the way the rats’ bones metabolized energy from food, disrupting the body’s response to a high-calorie diet.
“What was remarkable was that these changes lasted long after the rats stopped doing that extra exercise — into their mid-life,” commented Dr Justin O’Sullivan, a molecular geneticist at the Institute.
“The bone marrow carried a ‘memory’ of the effects of exercise. This is the first demonstration of a long-lasting effect of exercise past puberty.”
“The rats still got fat,” he pointed out, “but that early extra exercise basically set them up so that even though they put on weight they didn’t have the same profile of negative effects that is common with a high fat diet.”
Dr O’Sullivan says that the results may help explain why even though obesity and diabetes are often linked, not everyone who is obese develops diabetes.
“It also strongly emphasizes the health benefits of exercise for children.”
The team are now carrying out further research, varying the exercise and looking at the even longer-term effects into old age in the hope of recreating their results.
