PerformProCR

Shoulder Pain, the Hidden Cause

Daniel Rukeyser — Wed, 06 Dec 2023 17:21:16 +0000

Common Shoulder Pain Cause Your Doctor Might Not be Telling You.

Shoulder pain and rotator cuff injuries present a common and sometimes debilitating problem for athletes of any age. Scientists estimate that over 20% of older athletes and at least 10% of athletes under 20 years old will experience some shoulder pain, rotator cuff tear or degeneration resulting in time away from their activity, risk of future shoulder injury, and sometimes the need for surgery. Sometimes these injuries are caused by impact with other players or the ground, but often they are non-traumatic or micro-traumatic rotator cuff injuries. Is there a hidden cause of shoulder pain and injury that is often overlooked? Research and my own clinical experience tell me that there is, and it’s much easier to fix than you might expect.

What is the Rotator Cuff?

The rotator cuff is a group of four muscles and tendons that keep the head of the humerus (the upper arm bone) securely attached to the shoulder socket and are often the cause of shoulder pain. These muscles all originate at the scapula (the shoulder blade). The intricate interplay between the scapula and the rotator cuff muscles is crucial to shoulder function. One key factor in understanding this relationship is scapular upward rotation, a dynamic movement pivotal in maintaining optimal shoulder mechanics.

Often, in my Costa Rica Chiropractic practice, I will see patients complaining of non-traumatic shoulder pain. Sometimes they come in with MRIs showing rotator cuff tears. Typical orthopedic and physical therapy techniques including rest, steroids, and common rotator cuff exercises have failed to provide relief, prompting the patient to consider surgical intervention. But, many times there is another way.

Shoulder Pain has a Hidden Cause.

Most of the time, careful examination of the way the shoulder blade and the arm move shows an altered pattern of movement. This poor movement pattern is sometimes caused by shoulder pain, but might also be the original cause of the problem. Without fixing this movement pattern rotator cuff injuries may not heal and only get worse with time. This is true especially when steroid injections or anti-inflammatory drugs temporarily eliminate the pain.

The altered movement pattern is usually poor scapular upward rotation. That’s when the shoulder blade rotates upward to let the arm move overhead. When doesn’t rotate enough, the tendons of the rotator cuff get pinched by the bones of the shoulder and injury results.

Fix This and Fix Your Shoulder Pain.

Luckily with some specific manual therapy and some targeted shoulder blade exercises, the upward rotation can be fixed very quickly, eliminating the impingement and relieving the shoulder pain. The key is getting to it early. Even waiting to rest, taking drugs, injections and passive therapy like ultrasound or electric stimulation machines may waste valuable time. Addressing the mechanical cause of the impingement as soon as possible is critical.

Anyone with shoulder pain should ask their doctor or therapist if their scapular mechanics is a potential cause of their rotator cuff injury. Qualified doctors and therapist should target muscles and nerves involved in movement of the shoulder blade, the humerus, the clavicle and even the ribs and upper back.

The Key Muscles.

Key muscles are: the Trapezius, Levator Scapulae, Serratus Anterior, Latissimus Dorsi, Rhomboids, Pectoralis Major and Pectoralis Minor. Also, a careful examination of upper spine movement will be helpful. When shoulder pain is coupled with upper back and neck pain, treating those areas is often critical to full resolution.

Treatment should always include exercises to maintain or improve scapular upward rotation. Your healthcare provider should recommend exercises based upon your specific movement imbalance, and not one-size-fits-all exercises.

Understanding the intricate relationship between scapular upward rotation and rotator cuff health is crucial for preventing and addressing non-traumatic injuries. Physical therapists, athletes, and healthcare professionals should focus on exercises and interventions that promote optimal scapular mechanics to mitigate the risk of rotator cuff issues. By emphasizing the importance of scapular upward rotation in shoulder function, we can pave the way for improved injury prevention strategies and enhanced overall shoulder health.

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Is it Carpal Tunnel Syndrome?

Daniel Rukeyser — Thu, 02 Nov 2023 21:17:54 +0000

Exploring Conservative Treatments for Carpal Tunnel Syndrome and Other Peripheral Nerve Entrapments

Carpal Tunnel Syndrome (CTS) is a common condition that affects millions of people worldwide. It is characterized by pain, numbness, and weakness in the hand and wrist, often caused by compression of the median nerve as it passes through the carpal tunnel. While surgery is a well-established treatment option for CTS, conservative treatments, such as manual therapy techniques like nerve flossing and Active Release Technique (ART), have gained popularity as effective alternatives to surgery. This article will delve into the world of peripheral nerve entrapments, with a focus on CTS, and the potential of conservative therapies before opting for surgical intervention.

Understanding Carpal Tunnel Syndrome and Peripheral Nerve Entrapments

Carpal Tunnel Syndrome is one of the most recognized peripheral nerve entrapments. It occurs when the median nerve, responsible for controlling sensations and movements in the thumb, index, middle, and ring fingers, becomes compressed within the carpal tunnel—a narrow passageway in the wrist formed by bones and ligaments. This compression can lead to a variety of symptoms, including pain, tingling, numbness, and muscle weakness in the hand.

However, CTS is just one example of a peripheral nerve entrapment. Other common peripheral nerve entrapments include cubital tunnel syndrome (ulnar nerve compression at the elbow), thoracic outlet syndrome (compression of the brachial plexus in the neck and shoulder area), and radial tunnel syndrome (compression of the radial nerve in the forearm).

It is common for patients experiencing hand pain to be diagnosed with Carpal Tunnel Syndrome incorrectly. Many other nerve entrapments can cause hand and wrist pain. It is important to carefully examine the nerve at all possible entrapment points, as well as other structures in the upper extremity. At my Chiropractic Practice in Costa Rica, I often find other problems in the neck and forearm that are the true causes of hand and wrist pain.

Conservative Treatments for Peripheral Nerve Entrapments

Before considering surgical options for peripheral nerve entrapments, it is often advisable to explore conservative treatments. Manual therapy techniques, such as nerve flossing and Active Release Technique, have emerged as valuable alternatives that may help alleviate symptoms and improve quality of life for many patients.

Nerve Flossing: Nerve flossing is a therapeutic approach used to mobilize and release compressed nerves. This technique involves gentle, controlled movements designed to free the nerve from its entrapment. Nerve flossing can be beneficial for patients with CTS, cubital tunnel syndrome, and other nerve entrapments. By carefully guiding the nerve through its normal range of motion, it can relieve tension and reduce the pressure on the nerve, alleviating symptoms.

Active Release Technique (ART): ART is a soft tissue therapy that targets adhesions and scar tissue, which can contribute to nerve entrapment and compression. In ART, a trained practitioner uses their hands to apply specific tension and pressure to affected muscles and tissues, breaking down adhesions and facilitating healing. This technique can be effective for various peripheral nerve entrapments, helping to reduce pain and restore function.

Effectiveness of Conservative Therapies for Carpal Tunnel Syndrome

The effectiveness of conservative treatments for peripheral nerve entrapments like CTS and cubital tunnel syndrome has been well-documented. Many patients experience significant symptom relief and functional improvement without the need for surgery. These therapies are non-invasive, have minimal risks, and can be repeated as necessary to maintain results.

It is essential to work with a qualified healthcare provider, such as a physical therapist or chiropractor, who is trained in these manual therapy techniques. They can create personalized treatment plans and guide patients through the rehabilitation process.

Peripheral nerve entrapments, including Carpal Tunnel Syndrome, can cause significant discomfort and hinder daily activities. While surgical intervention is a viable option, conservative treatments like nerve flossing and Active Release Technique have proven to be effective in many cases. These non-invasive therapies provide patients with a chance to alleviate symptoms, improve function, and potentially avoid surgery. Always consult with a healthcare professional to determine the most suitable treatment approach for your specific condition.

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Stability: The Key to Performance.

Daniel Rukeyser — Mon, 30 Oct 2023 18:25:39 +0000

Increasing Stability Can Improve Movement in Athletes and Non-Athletes Alike.

Achieving peak athletic performance and preventing musculoskeletal injuries are top priorities for athletes at every level. While many focus on strength and flexibility, one crucial aspect that often goes overlooked is stability. Stability plays a vital role in optimizing athletic ability and safeguarding the body from injuries. In this article, we’ll explore the importance of stability in preventing musculoskeletal injury and improving athletic performance, with a particular focus on the revolutionary technique known as Dynamic Neuromuscular Stabilization (DNS). I began to learn the DNS almost twenty years ago, and it continues to be a key part of my Chiropractic Practice in Costa Rica.

The Significance of Stability

Stability can be defined as the body’s ability to maintain equilibrium and control during various movements and activities. In the context of sports and physical performance, stability is the foundation upon which all other attributes, like strength, speed, and agility, are built. Here’s why stability is of paramount importance:

Injury Prevention:

Stability is a significant factor in injury prevention. When the body lacks stability, athletes are more prone to musculoskeletal injuries, such as sprains, strains, and tears. The ability to control movements and maintain proper alignment is essential in reducing the risk of these injuries.

Enhanced Performance:

Stability is not just about preventing injuries but also about optimizing performance. Athletes with better stability can perform movements more efficiently, improving speed, power, and precision. Enhanced stability allows for quicker changes in direction and better balance, all of which are critical in many sports.

Dynamic Neuromuscular Stabilization (DNS)

Dynamic Neuromuscular Stabilization (DNS) is a revolutionary approach to stability training. Developed by Prof. Pavel Kolar, a renowned Czech physiotherapist, DNS is based on the idea that proper movement patterns are established during infancy. DNS focuses on re-establishing these fundamental, natural movement patterns to enhance stability, reduce the risk of injury, and optimize athletic performance.

Developmental Kinesiology:

DNS draws from the principles of developmental kinesiology, observing how infants learn to move and stabilize their bodies. By understanding these natural processes, DNS practitioners can help athletes regain these innate patterns and movements.

Functional Joint Centration:

DNS emphasizes maintaining the proper alignment and centration of joints during movements. This approach ensures that the body’s structures are in their most stable positions, reducing the risk of injury.

Core Activation:

DNS places a strong emphasis on core activation. A stable core is crucial for transmitting force efficiently and maintaining balance during athletic movements.

Breathing Patterns:

Proper breathing is essential for stability. DNS focuses on teaching athletes how to breathe effectively during physical activities, which can improve oxygenation, reduce muscle tension, and enhance overall stability.

Dynamic Neuromuscular Stabilization offers several benefits for athletes:

Injury Resilience: By re-establishing natural movement patterns and enhancing stability, athletes are less likely to experience injuries related to poor movement mechanics and instability.

Improved Performance: DNS helps athletes move more efficiently, resulting in improved speed, power, and agility. It also aids in the recovery and rehabilitation process, allowing athletes to return to their sport faster.

Enhanced Posture: DNS can contribute to better posture, both on and off the field. Proper alignment reduces stress on the musculoskeletal system, leading to less fatigue and better performance.

Reduced Pain and Discomfort: Athletes often experience pain and discomfort as a result of improper movements and instability. DNS can help alleviate these issues, allowing athletes to train and compete without hindrance.

The Importance of Stability for Non-Athletes:

1. Injury Prevention
Just as athletes benefit from stability to prevent injuries, non-athletes also require stability to reduce the risk of everyday injuries. Falls, slips, and accidents can happen to anyone, and having good stability can significantly lower the likelihood of injury in such situations.

2. Joint Health
Maintaining joint health is crucial for non-athletes who rely on their bodies for various tasks, from lifting groceries to climbing stairs. Stability exercises help distribute the forces on joints more evenly, reducing wear and tear, and ultimately promoting joint longevity.

3. Postural Support
Stability is closely tied to posture. Poor posture can lead to discomfort, pain, and even chronic conditions. Non-athletes who spend long hours sitting at desks, driving, or doing household chores can benefit greatly from stability exercises that promote good posture and spinal alignment.

4. Functional Independence
Non-athletes, especially as they age, need stability to maintain functional independence. Simple activities like getting up from a chair, reaching for items on high shelves, or bending down to tie shoelaces become easier and less risky with improved stability.

5. Pain Management
Many non-athletes suffer from chronic pain conditions such as lower back pain, arthritis, and joint pain. Stability exercises can help manage and alleviate these pains by strengthening the supporting muscles, improving alignment, and reducing the stress on painful areas.

6. Enhanced Quality of Life
Stability contributes to an overall better quality of life. Non-athletes who are stable in their movements experience less discomfort, greater mobility, and increased confidence in their day-to-day activities. This leads to a more active and fulfilling life.

7. Preventative Health
A stable body is less prone to health issues related to physical inactivity, including obesity and cardiovascular problems. Incorporating stability exercises into one’s routine can be a proactive step toward better health.

8. Aging Gracefully
As individuals age, they naturally experience a decrease in muscle mass and bone density. Stability exercises can help counteract these effects, ensuring that non-athletes maintain strength, balance, and mobility well into their later years.

9. Mental Well-being
Stability training is not just about the body; it also benefits the mind. Physical activity, including stability exercises, releases endorphins, which can help alleviate stress and improve mental health for non-athletes.

Incorporating Stability into Daily Life

Non-athletes can benefit from stability-enhancing methods similar to those used by athletes, such as functional training, yoga, and balance exercises. Additionally, the principles of Dynamic Neuromuscular Stabilization (DNS) can be applied to daily activities and exercise routines to promote stability and overall well-being.

By recognizing the importance of stability in daily life, individuals can maintain a higher quality of life, remain injury-free, and age with grace and vitality. Stability is not just a sports-specific attribute; it’s a fundamental component of living a healthy, active, and pain-free life.

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Do You Have Plantar Fasciitis?

Daniel Rukeyser — Tue, 12 Sep 2023 15:54:50 +0000

Foot pain can be a stubborn problem, but...

For some people, pain in the bottom of the foot can be just an annoyance during the first few steps out of bed in the morning. But for others, it can be a debilitating problem that can sideline even the most determined athlete. In my practice, patients often come in saying they have Plantar Fasciitis. Sometimes they do and sometimes they don’t. “Plantar Fasciitis” is one of the most common misdiagnoses that I encounter. This is understandable considering that there are many other causes of pain in the bottom of the foot. Here we will break down the most common causes of foot pain, what true Plantar Fasciitis really is, and how to treat it.

The worst thing you can do for Plantar Fasciitis!

First, what is Plantar Fasciitis? Even the name Plantar Fasciitis is misleading. First of all the anatomical structure that causes Plantar Fasciitis isn’t really fascia at all, it’s actually a type of aponeurosis, a thickened connection between the fascia and the bone. This is important because this tissue doesn’t get much blood supply and doesn’t really become swollen, as is implied by the “itis” name. So, when you understand this you know why a common treatment for Plantar Fasciitis is the absolute wrong thing to do! Since the problem isn’t inflammation, taking an anti-inflammatory won’t help. But worse than that, ibuprofen, a common anti-inflammatory recommended for Plantar Fasciitis probably contributes to stress fractures in the foot! This makes Ibuprofen the worst thing you can do for Plantar Fasciitis, yet it’s the most common recommendation!

The second worst thing you can do? Steroid injections. While this might be able to temporarily relieve plantar fascia pain, it will not cure the problem. Worse, steroid injections can cause the fat pad on the bottom of the heel to shrink, causing more pain and injury, plus they may cause the plantar fascia to rupture. Not what you want at all!

What is it?

In true Plantar Fasciitis, there is injury or damage to the connection between the Plantar Aponeurosis and the heel bone, or calcaneus. The cause seems to be entirely biomechanical in nature. And since my practice is based on solving the true cause of musculoskeletal problems, that’s where we’ll focus. It’s becoming clear through research that the number one cause of Plantar Fasciitis is reduced dorsiflexion of the ankle. That’s when the ankle does not flex (think of standing and bending your ankle so your knee moves forward) as much as it should.

How Do You Treat Plantar Fasciitis?

Many treatments can help the tissue heal faster, including Active Release Technique, dry needling, or extracorporeal shockwave therapy, even gently rolling the foot over a golf ball or frozen water bottle can help some people. However, the most important factor is changing the ability of the ankle to dorsiflex. A very careful examination of biomechanics, especially of the lower extremity is required and there are usually multiple causes of reduced dorsiflexion.

Some of the more common causes are tight or rigid calf muscles like the gastrocnemius and the soleus, poor function of the flexor hallucis longus (big toe) muscle, ankle joint capsule function, and ankle ligament function. All of these can usually be treated with manual therapy and exercise, but in most treatment protocols, they are ignored because they aren’t usually painful. Occasionally there is a more global problem. Weak or ineffective gluteus major muscles and poor core stability can both contribute to poor ankle function.

One of the greatest errors of all manual therapy treatments is the propensity to focus solely on the painful tissue. By taking a more “whole-body” approach we are often able to resolve even the most stubborn problems when many treatments have already failed.

When treatment of Plantar Fasciitis fails, it is often because the problem isn’t really Plantar Fasciitis at all. Pain on the bottom of the foot may be caused by other tissues. And each of these must be approached differently than Plantar Fasciitis. Some common causes of foot pain that are mistaken for Plantar Fasciitis are often overlooked.

Pain in the adductor hallicus muscle can resemble Plantar Fasciitis. Often this muscle of the big toe will be overworking when the gluteus maximus muscle is under-working. Another common cause of foot pain is a nerve entrapment on the bottom of the foot. Sometimes, a heel spur is the cause, although usually heel spurs that show up on X-rays are asymptomatic and not the cause of pain.

In order to resolve Plantar Fasciitis or any pain on the bottom of the foot, the first step must be a careful diagnosis. Understand, that there are many causes of foot pain and continually addressing the wrong tissue or ignoring the mechanical dysfunction that causes the irritation will undoubtedly lead to months or even years of frustration.

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Improving Your Fitness By Setting Goals

Daniel Rukeyser — Mon, 04 Sep 2023 19:41:04 +0000

Improving your fitness is no different than most aspects of your personal life, you optimize what is important to you. At least, that’s what we should do.

Most of the time we allow our efforts to be random and our results are just as random. As I get older, this becomes more clear: In relationships, work, leisure time, and fitness if I don’t intentionally dedicate myself to honest deliberation about what is important, my time is wasted on marginal returns and disappointing results. Entropy is automatic, but improvement is deliberate.

Dedication and consistency are also impossible without an understanding of the goal. To be clear, consistency is paramount here. You must be able and willing to stick with any plan in order to achieve results. If it’s not obvious to you already, research overwhelmingly demonstrates that improving your fitness is the backbone of a long and healthy life. For most of us it will be the difference between spending the last decade of our lives with sickness and disability or health and vibrancy.

Most of us think about fitness as a way to stay looking and feeling young and healthy, and these are typically byproducts of a good fitness regime. However, staying “fit” is actually your best weapon against most types of chronic diseases. We talk very often about the role diet plays in our cardiovascular and immunological health, but regular exercise is a necessary component to maximizing our healthspan, and this should top the list of fitness goals for everyone.

Maximize Healthspan by Improving Your Fitness

While increasing our healthspan, the period of life spent in good health, free from the chronic diseases and disabilities of aging, is a worthy goal, it’s not the only goal. The first step in creating a fitness plan that meets our needs is to understand our needs. To do that let’s talk about some fitness goals. This list is certainly not complete but it’s a great start and most of us will find at least one we can get on board with. This is an introduction to the most important components of improving your fitness.

Functional Movement

Let’s start with what we call Functional Movement. This can be understood as the ability of your body to maintain mobility and stability at the same time. At PerformPro, we begin each patient case with a thorough movement evaluation. This allows us to understand where limited or altered mechanics are contributing to, or causing pain and injury. We understand that this evaluation isn’t just the best way to begin our diagnostic process but also allows our serious athletes to identify key movement faults that may be reducing their ability to perform. Anyone who wants to learn a new sport, or skill, or improve ones they already do, needs to evaluate their Functional Movement.

Speed

Next is Speed. Here we are talking about maximum velocity or acceleration of the whole body. Think sprinting or speed work for runners. While speed, on its own, is not the most popular fitness goal out there, it does contribute to success in most sports. Plus, adding some speed goals offers some protection from injury to endurance athletes. The standard Speed test is the 20-meter sprint.
The basic 20-meter sprint test is completed after a sufficient warm-up and can be attempted more than once if enough rest is allowed between attempts. Simply, sprint from a standing position 20 meters and record the time. A fit male optimizing for speed should complete the 20-meter sprint in under 3.5 seconds, under 4.0 seconds for females. Elite male sprinters beat 3.0 seconds and females 3.5 seconds.

Power

Power is the maximum force you can produce in the shortest amount of time. Think explosive jumping or throwing. Power is critical to most sports and so, testing power in elite athletes is a complicated and fairly advanced science. However, for our purposes, there are simple ways you can evaluate your own power production at home or in the gym.
A very standard and easy test is the Vertical Jump Test. Standing next to a wall, reach up and mark the highest point you can touch. Then attempt to jump as high as possible over that mark. The difference is your Vertical Jump. A good fitness goal is 50-60 cm for males and 40-50 cm for females.

Strength

Strength is a very common fitness goal and one that should be on everyone’s list because of its healthspan-enhancing abilities. Testing strength is complex because it should be tested in different areas of the body. Even for our self-evaluation, multiple strength tests should be used.

A standard strength test is Grip Strength. For good reason, this study determined that grip strength was a better predictor of all-cause mortality than blood pressure! Usually, a dynamometer is used to measure the maximum grip strength of both hands. But, let’s use a simple Dead Hang test. Grab onto a pull-up bar, arms straight and feet off the ground. See how long you can hang on before losing your grip. Aim for at least 60 seconds (men and women).

Another gold standard strength test is the Leg Extension Test. Here a standard leg extension machine can be used. Using both legs, determine your one-repetition maximum weight. A good standard to aim for is your body weight.

Muscular Endurance

Muscular Endurance is your ability to repeatedly or consistently maintain muscular contractions against resistance. Think about repeated pull-ups or push-ups, kettlebell swings, or even repeated bench presses. Again, muscular endurance is required in most sports and improved muscular endurance allows for gains in strength, power and speed.
To test for muscular endurance, you can try a plank. You should aim for at least 60 seconds. Push-ups are a good test too. A goal of 25, without pausing, for men and 15 for women is ideal.

Aerobic Capacity

The final fitness component I recommend testing is your Aerobic Capacity. Some will know this as their VO2 max, which is the maximum amount of oxygen that your body can consume during physical activity. Because aerobic capacity is so important for athletes, there are very sophisticated testing centers dedicated to precise measurements of VO2 max. But aerobic capacity isn’t just for elite athletes. Anyone determined to become more fit should test and monitor their aerobic capacity. Luckily there are simple ways to test this.
The time-tested and still often used test is the 12-Minute Cooper’s Test. In this test, you get on a treadmill, or a track or use a GPS watch to measure distance and run as far as you can, on a flat surface, in 12 minutes. This can be done after a proper warm-up. For most people getting through 1.5 miles (2.4 km) is a worthy goal.

Improving Your Fitness Takes Commitment

Not sure where to begin in your fitness journey? I suggest starting with a good Functional Movement Evaluation. That way you can address any potential pitfalls, avoid injury, and make the most of your fitness work. Then, take about a week and, one at a time conduct each of the tests I listed above. Are any way below standards? If so, start by improving your fitness in those areas first. Are all looking pretty good? Great, continue to improve your fitness by setting goals to work towards. Maybe you want to complete a triathlon, and muscular endurance and aerobic capacity must be top of your list. Want to learn rock climbing? Put strength at the top.

The most important thing is to stay consistent and keep trying. The journey is the real goal. Keep it fun and make some friends along the way.

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Five Ways to Boost Your Kid’s Immune System.

Daniel Rukeyser — Sun, 20 Aug 2023 16:48:04 +0000

Back to School: Five Ways to Keep Your Kid’s Immune System Strong.

It’s back-to-school time for kids in the US and for private schools here in Costa Rica. That means seeing friends again after the summer break, meeting new kids and teachers, and sharing stories, toys, and sometimes lunches! It’s an exciting time for kids, parents, and teachers alike. But it’s also time for the back-to-school bout of illness. This year, you can do something about it, by strengthening your kid’s immune system.

Last year, a few weeks after the start of our small private school in Costa Rica, we started hearing about an alarming number of kids who were sick. Colds, the flu, then an unidentified stomach bug hit school hard. And, it wasn’t just our school. I heard from parents at other schools about how bad it was. I know our school has great cleaning protocols and the kids are outdoors a lot, so I began to think about why the situation seemed much worse than I expected.

Two Factors of Infection.

Why do some kids get sick and others don’t, even when they are in the same class? To understand this we must first discuss the two major factors in human infection. First, is pathogen exposure, or the amount and type of virus and bacteria that you are exposed to. In our school, it seems that families travel quite a bit. They go to their home countries and bring back local strains of viruses and bacteria, introducing them to our small community. With such a varied pathogen exposure, it’s much more likely that our children will be exposed to viruses or bacteria that they haven’t been exposed to before. In Costa Rica, this variation is exacerbated by the ideal environment for bacteria and viral growth. Travel is such an enriching experience and visiting with family back in the homeland is important. So, we want to keep doing that. It’s not something we can or will change.

The second factor is something that we can change. Our innate immunity is variable. Many factors increase or decrease a kid’s immune system. And some of these factors, especially the ones with the fastest and most dramatic effects are directly within our ability to modify. We can, but will we? After doing the research for this article, I realized that most of the immune-destroying habits come from our desire to have convenience in our lives. I undertsand this. Mornings can be a tough time, with lots to do and limited time. Getting ready and everyone out the door on time is stressful. But how much extra stress and inconvenience, not to mention suffering, is caused when our kids get sick?

Improve Your Kid's Immunity!

Some kids always get sick in the first few weeks of school. As parents, we brace ourselves for this. We had the back-to-school reminder talk last week with our son. “Remember to wash your hands before and after lunch, don’t rub your nose or eyes, and avoid sharing drinks…” It probably goes in one ear and out the other. But there is a lot more we can do to help our kids avoid common back-to-school illnesses!

Research clearly indicates that many of our choices determine, to a large degree the strength of our Immune System. And, with COVID, RSV (a serious respiratory virus), the Flu, and Impetigo, all expected to be major factors this year, it’s time to take a close look at what we CAN do! Here are five ways you can strengthen your kid’s Immune System heading into this school year.

1. Avoid Blood Sugar Spikes.

Multiple studies over the last decade have repeatedly confirmed that sugar is bad for the immune system. Just how bad, and for how long is also becoming increasingly clear. The amount of sugar in a typical sugary cereal breakfast, with juice can severely limit the ability of the immune system to fight bacteria and viral infections for a minimum of two hours and probably for a lot longer than that! That means when you give your kids a sugary breakfast (think cereal, waffles with syrup, or pastries) your sending them to school, where they will certainly encounter viruses and bacteria, without their normal kid’s immune system response.

2. Skip the Processed Stuff.

Highly processed foods and fast foods have been shown to disrupt kids’ immune systems not just for a few hours, but for days and weeks. While packaged, processed foods can make the morning routine easier, the cost of poor health and more frequent illness is too great to make the convenience worth it. Look for natural sources of fibrous carbohydrates, rather than processed corn and flour.

3. Subtract the Additives.

Many fast foods and processed foods contain harmful chemicals that have negative effects on our health. Eaten regularly these additives may cause psychological, digestive, and immune system problems. Fast food and most processed food contain phthalates, which can cause inflammation, disrupt natural hormone production, and reduce your kid’s immune system function. Another great reason to reject fast food and processed foods.

Polysorbate 80 and artificial colors are also indicated in psychological disturbances and have been shown to be detrimental to a kid’s Immune System. Not what we want when we send our child to school.

4. Get the Good Stuff!

Another advantage of avoiding processed foods and replacing them with healthy, whole foods is that your kids will get more essential vitamins and other nutrients that they need. It turns out that these essential vitamins and nutrients are critical for your kid’s immune system too. Natural sources of vitamin C (berries, citrus, and other fruits), vitamin E (nuts, seeds, and green leafy vegetables), carotenoids and polyphenols (bright colored fruits and vegetables), and dietary fiber (avocados, beans, and most vegetables) are critical for our health. Make sure that they are the bulk of your regular diet.

5. Replace the bad fats.

Not all fat is bad! However, there are some that we should always avoid and some that we need more of. We should eliminate all trans fats, like margarine and hydrogenated oils, the fats added to many processed foods. Research shows that an overabundance of Omega 6 fats, found in vegetable oils increases inflammation and may reduce your kid’s immune system. To counter this, try adding more Omega 3 fats. These can be found in small fatty fish, walnuts, flax seeds (linasa), chia seeds (or chan in Costa Rica), or in an Omega 3 supplement.

This year, let’s do more to increase our kid’s immune systems.

And, be aware that beyond hand washing, the choices you make regarding food are incredibly important. We all know that it can be tough to change our habits and food choice is one of the toughest. But taking small steps, and sticking with them will have a very large impact!

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Prime Hydration– Revolution or Revolting?

Daniel Rukeyser — Tue, 02 May 2023 18:26:38 +0000

My Take on Prime Hydration.

If you know me, you’ll know I tend to stay oblivious to super-hot trends. But Prime Hydration, this wildly popular sports drink caught my attention this weekend while spending some time with some very smart people and fellow chiropractors.

We tend to keep our diet fairly clean and limit our processed food intake to a few “special” items. The availability and omnipresence of toxic “foods” and the complexity of nutrition information make thoughtful and deliberate management of our families’ diets difficult.

All we can do is be open to information, be willing to spend some extra time and effort on our health and make our own informed decisions about food. The “ultimate healthy” diet is probably not a reality for most families but I think that most of us could use a bit of a push in that direction. That is why I get concerned when a processed food product gets so much hype and parents feel the pressure to allow their kids to consume it. That’s why I dug into Prime Hydration’s ingredient list.

Let’s be clear, this article is about Prime Hydration, not Prime Energy, which along with all energy drinks, is never appropriate for kids.

Are Supplemental Drinks Even Necessary for Kids?

Prime Hydration bills itself as a “better option” for sports drinks, that tend to be laden with sugar and artificial ingredients. But, are sports drinks even necessary for kids? Most nutritionists would argue that they aren’t necessary, for healthy kids even when playing sports. When kids are exercising intensely for over an hour and sweating profusely a sports drink may be a good way to replenish sugars and electrolytes, but water and a healthy meal is probably a better option.

So, is Prime Hydration any Better?

Prime does have a few things going for it. The Branched Chain Amino Acids found in Prime Hydration are an excellent way to reduce muscle breakdown with intense exercise and should be included in a high-level athlete’s nutrition plan.

It does have some coconut water, from concentrate which is a good source of potassium and is low in sugar. We encourage our son to drink lots of coconut water, straight out of the coconut, which is easy in Costa Rica. I don’t think the processed version in Prime can be compared.

It is low in sugar. However, the addition of the artificial sweetener sucralose is, in my opinion, worse than real sugar. Sucralose has been shown to alter insulin sensitivity and negatively affect the normal bacteria in the gut. Avoid added sugars but not by substituting them with artificial ones.

Troubling also is the use of dipotassium phosphate, an ingredient in fertilizer and antifreeze, and also used as a texturizer in some foods.

Acesulfame Potassium is another artificial sweetener found in Prime Hydration that is concerning to me. There just aren’t enough long-term studies on its use with kids.

The Bottom Line...

When it comes to processed foods, it is best to avoid them. However, for most families, this isn’t desired or practical. Each family must decide what foods are right for them. The decision should be made with health goals and personal tastes in mind. A product’s popularity, should not be a factor in this decision. Prime Hydration ingredients make it a “food to avoid” in my family. Is it better than the other sports drinks out there? In some ways it is. However, I wouldn’t go so far as to call this a “healthier alternative”.

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Do I Have Sciatica?

Daniel Rukeyser — Tue, 18 Apr 2023 19:07:11 +0000

Misunderstood Sciatica...

This is the first in a series of articles on often-misdiagnosed conditions.

Sciatica is one of the most commonly misdiagnosed conditions I see on a regular basis. So let’s talk about what it is, what it feels like, and the most common problems that cause similar symptoms.

Sciatica, or ‘ciatica’ in Spanish, is the common term to describe any pain along the sciatic nerve. This is a thick (often as thick as your thumb) and long nerve that runs from the low back, along the buttocks, and back of the leg. Your pain can be at any point along the nerve pathway. Even though the sciatic nerve technically ends where it splits into other nerves, pain can run down any of those branches into the lower leg and foot.

Even though most people and many doctors use the term ‘sciatica’ this way, the true diagnosis of sciatica should be reserved for lower extremity radiculopathy. That’s when the small nerve roots are compressed and inflamed from a herniated disc in the low back. But since this is NOT usually the cause of pain along the buttocks and back of the leg, “sciatica” is one of the most commonly misused terms in health care.

True Sciatica.

In true sciatica, a herniated disc (HD), or other lesions in the lumbar spine causes compression and inflammation of the nerve roots that make up the sciatic nerve. Pain runs down the leg and is felt below the knee and sometimes into the foot. Pain that does not run past the knee is almost certainly not true sciatica. This is important to understand because sciatic pain caused by an HD needs very different treatment than other types of sciatic pain. The HD that causes true sciatica sometimes requires epidural injections or surgery. Still, I frequently meet new patients that have undergone invasive treatment for an HD when their pain clearly was not true sciatica. Many doctors are guilty of making this mistake and leading their patients down the wrong path of painkillers, injections, and even surgery based on sloppy diagnoses.

Other Causes.

Referred Low Back Pain.

Much more frequently, sciatic pain is caused by some other factor. Often referred pain from the low back can run down into the buttocks or leg, but is not related to an HD or nerve root compression. Even if a mild herniated disc can be seen on an MRI, it may not be the cause of the pain. Jumping right into treatment for the disc without careful consideration is a great injustice to trusting patients. Usually, gentle exercises, chiropractic, or manual therapy can reduce the cause of low back pain and the referred pain that goes with it.

Piriformis Syndrome.

An often misdiagnosed problem, piriformis syndrome can cause pain in the buttocks and down the back of the leg and is often mistaken for sciatica. The piriformis muscle is a muscle of the hip much like the rotator cuff of the shoulder. Since the sciatic nerve passes around (or sometimes through!) this muscle, any problem with it can often cause pressure or inflammation on the nerve. Commonly, I find the sciatic nerve entrapped by the piriformis muscle, causing severe pain in the buttock and leg. Luckily, this can usually be fixed quickly and easily with some manual therapy, and weeks, months, or even years of pain can be eliminated very quickly!

Peripheral Nerve Entrapment.

Like the sciatic nerve at the piriformis muscle, the branches of the nerve can be entrapped in other muscles further down the leg. The back of the knee or the top of the calf is a very common place for this to happen. Often runners will suffer this type of nerve entrapment after heavy training or if they have cramped up during a run or a race. Because there can be pain, numbness, tingling, or weakness associated with lower leg nerve entrapment, sciatica is often the (mis)diagnosis. However, with a careful exam, the entrapment can be identified and released very easily, with the right treatment.

The Right Diagnosis Leads to the Right Treatment.

At my practice in Tamarindo, Costa Rica, I often help patients that have been through failed treatment for sciatica, including painkillers, injections, and even surgery. But with careful diagnosis and the correct treatment, most causes of “sciatica” can be relieved quickly and completely.

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Mountain Biking: Knee Pain

Daniel Rukeyser — Mon, 27 Mar 2023 17:22:59 +0000

Solve Mountain Biking Knee Pain for Good!

At least one out of three mountain bikers will suffer from knee pain at some point. Along with low back and neck pain, knee pain is among the most common overuse injuries a mountain biker will face. Often, a good bike adjustment, proper fitting and smart gear shifting can help quite a bit. But, sometimes there are biomechanical causes of mountain biking knee pain that must be corrected. In my Active Release Technique chiropractic practice in Tamarindo, Costa Rica, I treat knee pain often. Here are the most common causes and treatments.

Most often knee pain is caused by one or more alterations of lower body mechanics. We can correct most of these problems with manual therapy, improving mobility, stability, and strength in different areas. Often, the treatment must be at regions around the knee, like the hip or ankle. Here at PerfromPro, we look at knee movement in relationship to foot/ankle, hip, and low back movement. Any treatment that only considers the knee will surely fail at resolving the problem over the long-term.

Anterior Knee Pain

One of the most common types of knee pain in mountain bikers is anterior knee pain or patellofemoral pain syndrome (PFPS).

PFPS is a condition that affects the patella or kneecap and the femur or thigh bone. The patella normally glides smoothly over the femur during movements such as bending or straightening the knee. However, in PFPS, the patella does not track properly over the femur, causing pain and discomfort and can cause tissue damage to the cartilage of the knee.

Symptoms of PFPS typically include a dull ache or pain at the front of the knee, especially when climbing uphill, using high gears, or at a low cadence. The pain may also be aggravated by activities such as squatting, kneeling, or jumping.

A common cause of PFPS is overtraining or not enough rest and recovery time. Other risk factors for PFPS include weak or tight muscles around the knee joint, such as the quadriceps or hamstrings, as well as imbalances in the muscles of the hip and pelvis. These imbalances can cause abnormal knee mechanics and increase the stress on the patella.

Fortunately, there are several steps you can take to prevent or manage PFPS as a mountain biker. Firstly, it’s important to ensure that your bike is properly fitted to your body and that you are using the correct technique when riding.

Stretching and strengthening exercises can also be helpful in preventing and managing PFPS. Specific exercises that target the quadriceps, like weighted knee extensions, can help. Increasing the flexibility of the hamstrings is important. When soft tissue adhesions prevent hamstring flexibility, that must be addressed either with self-myofascial release or by a professional manual therapist.

Lateral Knee Pain

Pain on the side of the knee while mountain biking is often due to IT Band Syndrome (ITBS). This is when the thick fascia band that runs from the hip to the outside of the knee becomes irritated. Pain is often felt on the outside or under the front of the knee.

The cause of ITBS is often farther away from the knee than you might expect. Often, the IT Band can become tightly adhered to the side of the quadricep muscle. These two tissues are supposed to move in different directions during the pedaling cycle, when they can’t, the IT Band will become irritated. In this case, treatment is often manual therapy to eliminate the adhesion between these two anatomical structures.

As is often the case with Low Back Pain in Mountain Bikers, knee pain is often the result of core instability, weakness or fatigue. The force produced by the legs while riding can only be allied to the pedals if there is a bracing force produced by the core muscles. When weakness or fatigue reduces this bracing force, the leg will move inefficiently, reducing power and causing injury.

In order to prevent ITBS you should improve core stability and strength. Exercises like planks, bridges, and bird-dog can be very effective in increasing core strength. Increasing the strength of the hip stabilizers is also critical. Targeting the lateral hip muscles like the TFL and gluteus medius, with a clamshell progression can increase the stability and power of the hip. This, in turn, reduces damaging forces on the knee.

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Tennis Elbow, Causes and Solutions.

Daniel Rukeyser — Fri, 17 Mar 2023 18:08:44 +0000

What Causes Tennis Elbow?

Lateral epicondylitis, commonly known as tennis elbow, is a condition that causes pain and inflammation in the outer part of the elbow. Tennis players are especially prone to developing this condition, in fact, research indicates that at least half of all tennis players will experience tennis elbow at some point. But, it can affect anyone who performs repetitive motions with the wrist and forearm.

The biomechanical causes of tennis elbow are often related to the mechanics of the backhand stroke. During the backhand, the wrist and forearm muscles are used to generate force and control the racquet head. When these muscles are overused or strained, they can develop tiny tears in the tendons that attach them to the lateral epicondyle, a bony bump on the outside of the elbow. Over time, these tears can lead to inflammation and pain. In the past, it was believed that tennis elbow was mostly an inflammatory problem, but now we know that damage or degeneration of the tendons is the main cause.

To treat tennis elbow, athletes should first rest the affected arm and avoid any activities that cause pain. This may mean taking a break from tennis or other sports for a period of time. Ice and compression can also be helpful in reducing inflammation and pain. Over-the-counter pain medications like ibuprofen or acetaminophen can be used to manage pain as well. However, controlling the inflammation is only a small part of resolving tennis elbow.

Controlling the inflammation is only a small part...

Manual therapy, like Active Release Technique, can be an effective treatment option for tennis elbow. A therapist can also teach athletes exercises to strengthen the wrist and forearm muscles and stretching and massage techniques to help improve flexibility and reduce pain. But, the full resolution must include observation and correction of bigger movement patterns in related areas of the body.

Using the wrong form during a backhand can put undue stress on the elbow, leading to the development of tennis elbow. This is because the backhand stroke requires complex coordination of the wrist and forearm muscles to generate power and control the racquet head. If the technique is incorrect, the muscles may be subjected to excessive force, leading to overuse and subsequent injury.

Research has shown that highly skilled players tend to experience less tennis elbow than less skilled players. This is likely due to their ability to hit the backhand with the wrist in extension, which puts the muscles in a stronger position and protects them from injury. In contrast, less skilled players tend to hit the backhand with the wrist in a flexed position, which places more stress on the muscles at the point of impact and increases the risk of injury.

Using a two-handed backhand is also believed to be better for preventing tennis elbow. By using both hands on the racquet, the force of impact is distributed more evenly across the muscles of both arms, reducing the stress on any one muscle group. This can help prevent overuse and subsequent injury to the wrist and forearm muscles.

Exercises for Tennis Elbow.

Improving the strength of the shoulder and wrist muscles can help prevent tennis elbow by reducing the stress on the forearm muscles during the backhand stroke. When the shoulder and wrist are strong, they can better support the racquet and absorb the force generated during the stroke, which can reduce the load on the forearm muscles.

There are several exercises that can help improve shoulder and wrist strength. Some examples include:

Shoulder external rotation: This exercise targets the rotator cuff muscles, which are important for stabilizing the shoulder joint. Start by holding a resistance band with your elbow bent to 90 degrees and your forearm parallel to the ground. Keeping your elbow at your side, rotate your forearm outward as far as you can, then slowly return to the starting position. Repeat for several repetitions on each arm.

Shoulder press: This exercise targets the deltoid muscles in the shoulder. Start by holding a dumbbell in each hand at shoulder level, with your elbows bent and your palms facing forward. Press the weights up above your head, then slowly lower them back down to shoulder level. Repeat for several repetitions.

Wrist curls: This exercise targets the muscles in the forearm and wrist that are used during the backhand stroke. Start by holding a weight in your hand with your palm facing up. Slowly curl your wrist upward, then slowly lower it back down. Repeat for several repetitions on each arm.

Reverse wrist curls: This exercise targets the muscles in the forearm and wrist that are used during the forehand stroke. Start by holding a weight in your hand with your palm facing down. Slowly curl your wrist upward, then slowly lower it back down. Repeat for several repetitions on each arm.

By incorporating these exercises into your regular training routine, you can improve the strength of your shoulder and wrist muscles and reduce the risk of developing tennis elbow. It’s important to start with light weights and gradually increase the resistance as your muscles become stronger. Additionally, it’s important to maintain good form and avoid overexerting the muscles, as this can increase the risk of injury.

Spine Mobility and Tennis Elbow.

Poor thoracic spine mobility can also be a factor in the development of tennis elbow. The thoracic spine is the middle portion of the spine, consisting of 12 vertebrae that connect the cervical spine (neck) to the lumbar spine (lower back). Limited mobility in this area can lead to compensations in other areas of the body, including the shoulder and elbow, which can increase the risk of injury.

When the thoracic spine is mobile, it allows for proper rotation and extension of the upper body, which is important for generating power and control during the backhand stroke. However, when the thoracic spine is stiff or limited in mobility, it can cause compensations in the shoulder and elbow, leading to increased strain and potential injury.

To improve thoracic spine mobility, there are several exercises that can be done. Some examples include:

Thoracic extension: Start by lying on your back with a foam roller positioned horizontally across your upper back. Place your hands behind your head, elbows out to the sides. Slowly extend over the roller, arching your upper back. Hold for several seconds, then return to the starting position. Repeat for several repetitions.

Thoracic rotation: Start by sitting on the floor with your knees bent and feet flat on the ground. Cross your arms over your chest and rotate your torso to one side as far as you can, keeping your hips facing forward. Hold for several seconds, then return to the starting position and repeat on the other side.

Cat-cow stretch: Start on your hands and knees with your wrists directly under your shoulders and your knees directly under your hips. Inhale and arch your back, lifting your chest and tailbone towards the ceiling (cow pose). Exhale and round your spine, tucking your chin to your chest and bringing your tailbone towards your knees (cat pose). Repeat for several repetitions.

Forearm Brace isn't Very Effective.

While treating the inflamed tendon is important in managing tennis elbow, it’s not the only factor to consider. As mentioned earlier, changes in stroke mechanics, improving shoulder and wrist strength, and promoting thoracic spine mobility can also play a role in preventing and managing tennis elbow.

In a study published in the American Journal of Sports Medicine, researchers examined the effectiveness of various treatments for tennis elbow, including changes in stroke mechanics, using an elastic forearm brace, and a combination of the two. The results showed that changes in stroke mechanics were the most effective treatment, with 63% of participants experiencing significant improvement in symptoms. However, using an elastic forearm brace was found to be the least effective, with only 25% of participants experiencing significant improvement in symptoms.

These findings suggest that treatment and prevention of tennis elbow must be focused on looking at broader biomechanics and not simply addressing the inflamed tendon. By improving stroke mechanics, strengthening the shoulder and wrist muscles, and promoting thoracic spine mobility, athletes can reduce the risk of developing tennis elbow and improve their overall performance on the court. It’s important to work with a qualified healthcare professional or sports coach to develop a comprehensive treatment and prevention plan that is tailored to your individual needs and goals.

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