Blog | Chandler Collins, DC

Get Even

by Dr. Collins on 14 Feb 2014
in Back Pain / Cycling / Knee Pain

Here’s the scenario: a cyclist has back, hip, or knee pain, and ends up in the office of a local health practitioner, or in the hands of the bike fitter at the local shop. He’s told he has a difference in his leg lengths, and the asymmetrical wear and tear may be causing his pain.

It’s certainly plausible. Many of us have noticed riders ahead of us in the peloton who seem to have one hip that drops lower with every pedal stroke. That has to be originating from somewhere, right?

So what’s going on? How’d our rider get this way, and what can be done to address the problem?

The difference in leg lengths doesn’t start with the feet. The most common cause of a leg length discrepancy is displaced rotation, or torque, of the pelvis.

The two sides of your pelvis rotate forward and back when you walk, run, or turn over the pedals. When your foot goes over the top of the pedal stroke, the top of your pelvis — the ilium — has to rotate back, or posterior, to accommodate it. The opposite happens at the bottom of the stroke, where your pelvis rotates forward, or anterior.

With posterior rotation your thigh bone, or femur, gets pulled up closer to your head, making that leg temporarily shorter than the other. Due to a fall or some other kind of trauma, one side can get “stuck” in a relatively more anterior or posterior position, producing a functional leg length discrepancy.

Actual anatomical differences in leg lengths — where one or more bones are altered making one leg significantly longer than the other — are rare. You’ll see these in people who’ve had a fracture or some other significant trauma to their pelvis or legs. Knee and hip replacements are also good culprits.

I see dozens of people every week that have leg length differences, but since the vast majority are functional adaptations to some other problem, it’s rare that they can’t be fixed with treatment.

Typically, the longer someone has had the problem, the longer it takes to address. By it’s nature an athlete’s body is good at working around problems, so facilitating the release of a hard-fought adaptation like a leg length difference requires creative and thorough treatment.

A good bike fitter can be the first to catch this kind of problem. Making small positional changes or placing shims in shoes is a frequent fix for a leg length difference. These folks are wizards at getting you into a comfortable, efficient position on the bike, and reducing some of the biomechanical strain that can come from being asymmetrically positioned can be a god-send.

This is especially true if you have an anatomical difference in leg lengths. However, a functionally adapted short leg shouldn’t be propped up over the long-term with a shim or heel lift. Unless you know you’ve had trauma to your lower extremities, or you’ve had your pelvis and legs X-rayed to confirm there’s an anatomical difference, the chances are your discrepancy is functional.

Ultimately, getting yourself evened out through thorough treatment is the best way to reduce wear and tear, and increase your health and performance.

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Got Iron?

by Dr. Collins on 13 Feb 2014
in Diet and Nutrition / Exercise, Training, and Fitness

An iron loop

In “The Risk of Training,” we talked about the stress of exercise, and how fitness and health are not synonymous terms. This time we’re going to look at some evidence of how training can have detrimental effects without careful management, and we’re going to start with a substance that is crucial to your existence: oxygen.

Most athletes understand that they must have oxygen in plentiful supply to fuel their training and racing endeavors. Aside from the important issue of training intensity and how it impacts our ability to use oxygen, what about the baseline ability of our body to carry oxygen?

Oxygen is carried in our red blood cells (RBCs), and when our RBCs get low in number it is referred to as anemia. Hemoglobin is the iron-containing molecule found within our RBCs that is largely responsible for transporting oxygen in the blood. Thus, if the number (or percentage) of RBCs in our blood declines, so does our ability to transport and utilize oxygen.

We’ve already talked about the fact that exercise is a stress, and like any other stress, it has its consequences. For athletes, one of the many consequences of regular training is a higher rate of iron deficiency. This can directly impact the ability to form hemoglobin and carry oxygen.

There are many reasons why athletes might be more susceptible to this problem. Chief among them is the fact that during exercise, RBCs shoot through our capillaries at high speed. A capillary is about the size of one RBC, so many RBCs actually break open, or lyse, due to the mechanical stress. When the RBC lyses, the iron-containing hemoglobin within it spills out into the bloodstream.

Athletes produce many acidic substances. One is lactic acid, and another, as a byproduct of aerobic energy production, is excess hydrogen ions (where the “H” in pH comes from, as a measure of your acid/base status).

Guyton’s Textbook of Medical Physiology (a bible of the field if ever there was one) identifies hemoglobin as an extremely potent buffer of acidity. As a result, one idea about why athletes tend to be more iron deficient is that the hemoglobin gets used up as an acid buffer in the normal course of exercise, to be later excreted in the urine.

So how do you know if you’re deficient? A standard check of iron in the blood — your serum iron status — is insufficient. Bodies do a very good job of keeping readily available mineral markers like this steady, making them poor indicators of developing problems until things are really out of hand.

Ferritin, or stored iron, is a much more useful measure. Even with this marker, however, the stated “normal” ranges as listed on laboratory paperwork are much too broad. The ranges you see coming straight from the lab itself are, generally speaking, statistical averages of the entire pool of tests performed.

I know of no athlete who is satisfied with being average. The local office of the mega-lab we send patients to for blood work lists “normal” ranges for ferritin from a low of 10 ng/ml to a high of 291 ng/ml. This range is so wide that you’ll come crawling into your doctor’s office if you fall outside it.

In checking athletes in my office and in work with the University of Texas athletic department, we’ve found that people tend to be symptomatic with ferritin levels below 30 ng/ml. For optimal health and performance, we like to see values above 60 ng/ml.

If you’re an athlete, you owe it to yourself to get this checked. There are many other things that could contribute to an anemic state, impacting your ability to feed much-needed oxygen to your tissues. However, iron status is one of the easiest and cheapest to both check and correct. A simple CBC (complete blood count) along with ferritin shouldn’t set you back more than about $50 at your doctor’s office.

Your doctor should be able to help you select a high-quality, easily absorbed form of iron that will allow you to quickly correct the condition. Getting this checked is doubly important for premenopausal females, who are at an increased risk due to regular blood loss from menstrual cycles.

No matter what you do, keep in mind that your training has consequences! Staying on top of your health and respecting the stress that exercise causes is the best way to ensure longevity in both training and life.

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It’s All Downhill From Here

by Dr. Collins on 12 Feb 2014
in Exercise, Training, and Fitness / Stress

If we ignore the current trend in professional sports to seek external, pharmacological help, there really aren’t any magic fixes for athletic performance enhancement. If our training techniques are optimal — and that’s a big “if” — then the methods available to try and take yourself to the next level are limited.

As usual, the trick is to get more fitness while preserving your health. Check out some earlier articles in this space to understand how the drive to improve our fitness can potentially negatively impact our health.

So, within these constraints, how do you get an edge? There are several techniques that have been used by both Olympic teams and weekend-warriors. Some are more available to the amateur athlete than others.

We’ll explore a few, break down the basic concept behind them all, and then finish off with a technique that can be used by anyone in day-to-day training.

More Air Please

Not too long ago the US Olympic Speedskating team was rumoured to have used supplemental oxygen to train its athletes. Team members put on masks that supplied oxygen at levels above normal atmospheric concentrations while they performed their usual workouts.

The idea was to provide “extra” oxygen to the athletes’ muscles, allowing them to engage a higher percentage of muscle fibers than they would otherwise. In so doing, the thinking went, they would be able to more effectively train a larger percentage of their muscle fibers than they would without supplemental oxygen.

Given the phenomenal success US Speedskaters had at the 2002 games in Salt Lake, many believe the technique is effective. It was an idea born out of the now popular “live high, train low” approach of having an athlete perform workouts at a lower elevation, enabling him to work out harder, while living at a higher elevation, reaping the benefits of the increased ability of his blood to carry oxygen after acclimatization.

Cool Down First

Everyone knows that you tend to get warmer when you exercise. In particular, the harder you workout the hotter you seem to get. It should come as no surprise then, to learn that world records in endurance sports are routinely set in cooler conditions.

Well, what would happen if you had a way to keep your body temperature cool, or even pre-cool it prior to exercise? This is exactly what the Australians did prior to the 1996 Olympics, with the development of a special ice jacket for their athletes.

The jacket was supposed to keep an athlete’s body temperature down in hot and humid conditions. With the body working under artificially cooler climes, it might be able to produce performances akin to the world record results seen when the mercury drops well below a normally comfortable 72 degrees.

Suspend Your Activity

When the media covered the amazing story of the thoroughbred Barbaro’s win at the Kentucky Derby and subsequent on-the-track injury, we were bombarded by video and photos of the horse suspended by a special pulley system to facilitate his movement and recovery (see http://sportsillustrated.cnn.com/multimedia/photo_gallery/0605/gallery.barbaro/content.1.html).

Similar contraptions exist for humans, too, when recovering from injuries that render us unable to support our full weight when we walk.

These devices support the pelvis, effectively reducing the weight that our legs have to bear while we walk on a treadmill. We can thereby retrain muscles that have lost strength due to trauma.

Instead of being used after an accident, what if we used such a device in training for competition? By removing a mere 10 lbs. of the load our legs have to bear under normal circumstances (and if you don’t think that’s a lot, try heading out for a 30 minute run carrying a 10 lb. weight next time), we’d be able to perform workouts at a much higher intensity, engaging, and thus training, a higher percentage of our muscle fibers.

And the Connection Is?

What do all these things have in common? Reduced stress. The technique applied reduces the stress from gravity, heat, or lack of oxygen.

In all cases an attempt is made to free the body of what is a common stressor, one that under normal circumstances would be considered unavoidable. In so doing, physiological resources become available to be applied to a not-so-common variable: the stress of training.

Unfortunately, all of these require specialized equipment and training to employ. So how can you and I get in on the action?

Go Downhill

Dr. Phil Maffetone, coach of six-time Ironman World Championship winner Mark Allen, recommends using a normal training tool: hills. Only this time, you’re not concentrating on going up the hill for its physiological benefit, but down the hill. The very thing that makes going downhill easy — lack of gravity stress — is what will allow you to push your muscles that little bit extra for an added training effect.

Whether doing this on the bike or on two feet, choose a long, gradual downhill section that will allow you to do some moderate intervals for at least 3-4 minutes. The longer the better.

Your pace should be right at the edge of your aerobic threshold. If you’re coming up on racing season and you’ve spent a few months steadily building your aerobic base, doing anaerobic threshold intervals downhill are appropriate too.

Play it safe, though. You can pick up a lot of steam headed downhill on the bike, so stay aware and keep your hands close to the brakes.

Improper form running downhill is also a great way to pick up a case of plantar fasciitis. The repetitive pounding on your calcaneus, or heal bone, is a common way to knock that bone out of position and inflame the connective tissue on the sole of your foot, the plantar fascia. Shorten your stride and stay off your heals, which is a good plan no matter what your running terrain.

Remember, it’s the downhill portion of the interval that’s important, so take it easy headed back to the top, spinning in a light gear on the bike, and jogging lightly, or even walking, when on foot.

This isn’t all to say that working the uphill portion of your terrain is useless. The strength-building benefits of uphill intervals are well known. Using the other side of the rise is a great way to change up your training and add a little extra to your routine, with little added stress.

Finding ways to effectively lower your total stress and still achieve good training adaptation will keep you healthy long enough to get optimally fit! Have fun!

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Psoas Strain and Back Pain

by Dr. Collins on 11 Feb 2014
in Back Pain / Sciatica

I had a patient come in a few days ago who got up that morning, bent over to pick up an exercise mat, and was unable to come back up due to excruciating pain in her lower back. I hear this kind of story frequently.

People come in, bewildered, wondering how doing something that they’ve done hundreds of times before, on that particular day, could literally drop them to their knees in pain. How is it that picking up something as light as a fold-up exercise mat could make your back “seize up”?

Clearly, it wasn’t the mat that did it.

The Most Important Muscle in Your Back

To understand what the real culprit is, we need to go over some basic anatomy. Specifically, we need to get intimately acquainted with the psoas muscle (pronounced SO-UHS).

The psoas is a large muscle, deep in the core of your body. It originates from all of the vertebrae and discs (in between the vertebrae) in your lower back. It inserts deep in your groin area, on the inside of your femur, or thigh bone.

It’s a thick muscle. Well developed, it’s about as big around as your lower forearm.

Keep in mind that a muscle’s strength is directly proportional to it’s cross-sectional area. Roughly translated, that means the larger the muscle, the greater it’s ability to generate force.

A muscle with a diameter equal to the size of your forearm is pretty respectable. Most people’s bicep muscle in the upper arm isn’t near that size. This means the psoas has power. Power to move, and power to do damage.

Psoas Muscle

If you take a look at the illustration above, the psoas is the muscle that originates in strands from all of the vertebrae in the lower back, then travels deep through the pelvic opening, inserting on the inside of the femur below the hip joint.

Your spine needs similar help. Your back would not be stable if your spine simply stuck straight up from your pelvis with no assistance from other structures. Your psoas muscles provide a great deal of this support.

Without healthy, strong psoas function, your back just isn’t happy.

In addition, the psoas is one of your primary hip flexors. This means one of it’s main jobs is to bring your knees closer to your chest. Anytime you’re bent over, sitting, doing sit-ups, or performing your best cannonball into the pool, the psoas is potentially in a contracted, or shortened, position.

So What Happened?

This is significant for our exercise-mat-retrieving victim above. The psoas, just like any other muscle, can cramp or spasm.

If you’ve ever had a cramp in your calf or the back of your thigh, you might have noticed that these muscles tend to cramp when the muscle is shortened, not when it’s stretched out. You also probably intuitively stood up to stretch out the muscle to relieve the cramp.

Take a look at the illustration of the psoas again. The psoas runs down the front of your spine. It’s main job is to bend you forward or bring your knees closer to your chest. This means that the only way to really stretch it out well is to bend over backwards.

Most of us don’t do this very well.

So if you happen to be bending over to pick up a pencil, and your psoas decides to go into full blown spasm, you don’t have an easy remedy! It’s exactly like having a cramp in your calf but not having any way to relieve it.

If you can imagine this, you now know why a psoas spasm can be so debilitating.

In Practice

In my practice, for anyone with back pain this means the psoas gets a lot of attention. Muscles tend to “shut off” when our bodies are under stress, just like an overloaded circuit in your house (see the article “Why You Have an Athletic Injury” for more on this concept).

I thoroughly test these muscles to make sure my patient is getting the support they need around their core and lower back. On most people, psoas muscles that aren’t working well are usually (painfully) obvious.

For someone who’s had a psoas spasm, the muscle will usually test very weak after a sustained contraction. I then use techniques that help to lengthen and relax the muscle without forcing them into yoga-like moves to bend over backwards.

Adjustments of the lower back and addressing pelvic torque are also key to reducing the propensity for this muscle to seize up again.

As with any muscle cramp, dehydration can be a key factor inducing the psoas to spasm. Many of the stories I hear of people who’s back suddenly “grabbed” on them start out with a description of a long day spent gardening, out in the sun, or working out.

So put yourself in that same scenario, but this time with a new approach. You bend down to pick something up. All of a sudden, a sharp pain hits you in your lower back.

Don’t ask yourself what was different about the way you reached down this time. Ask yourself what is different in you that caused you to not have the muscular support to do something you’ve done hundreds of times.

Is it dehydration? Have you had other lower back “twinges” or discomfort that might have been your body’s way of telling you that everything wasn’t quite perfect? Do you feel “twisted”, with one hip or shoulder higher than the other?

If you can’t clearly answer questions like those and address the problem, get some help to do just that. Your body will thank you, and seemingly innocuous exercise mats will no longer be your nemesis!

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Set Up Your Space

by Dr. Collins on 10 Feb 2014
in Back Pain / Carpal Tunnel / Neck Pain / Numbness / Posture and Ergonomics / Sciatica

It wasn’t my habit years ago to walk into your average office and cringe at the sight of workers sitting at their desks. I have to confess that that sort of reaction is exactly what takes hold of me nowadays.

After seeing many patients that need treatment for everything from numbness and tingling in their fingers to debilitating lower back pain, it quickly became obvious that the desk posture of the average American office worker really isn’t working out. Home computer users needed plenty of help, too.

This article is dedicated to those of us who’ve made the jump to the information age. If you use a computer, read up. You need this information.

We’re going to walk step by step through setting up your computer workspace. You’ll be rewarded with a much less stressful setup that will treat you better long term.

A Good Foundation

We start with your chair. The more adjustable, the better. The base, or seat, of the chair should not only raise and lower, but ideally it should be able to tilt forward and back.

That is, the edge of the base that is closest to your knees should be able to lower relative to the edge that is closest to the back support.

You need the base of the chair higher than you think. You want to be able to raise the base so that your hips are significantly higher than your knees. Say, at least 4-5 inches.

Stand up. Place one hand at the small of your back and the other on your tail bone. Keeping your hands where they are, slowly sit down onto a low chair that has your hips even with your knees. Feel how your lower back rounds out substantially?

Now start over in the standing position. This time, sit down onto a taller chair, stool, or even a tabletop so that your hips are well above your knees.

You should notice that your lower back doesn’t round out as much, keeping your spine in a more neutral position and the weight of your torso centered through your pelvis. When you’re in the right position, even your feet will feel more grounded on the floor.

Here’s where the base tilt comes into play. With your hips higher than your knees, on some chairs the front edge of the base will dig into the backs of your thighs.

Tilting the front edge of the base downward eliminates this pressure, and also has the beneficial side-effect of slightly rocking your pelvis forward into an even better position.

If your chair doesn’t have this feature, you can accomplish the same thing with a small pillow or wedge, with the thick part toward the back.

Now that the base is at the optimal height and tilt, you should be able to sit comfortably, balanced, without the need for any particular back support. This is the reason most people sit with better posture on an inflatable exercise ball.

Sitting on an exercise ball, your hips are typically higher than your knees, and the natural curvature of the ball tends to rock the pelvis slightly forward so that you are balanced over what yoga practitioners call your “sit bones”.

Anatomically these are known as the ischiums, and they make up the part of your pelvis that is closest to the ground. You can feel them simply by putting your hands under your buttocks when you’re sitting.

Balance is key. If our spine is centered over our pelvis, it takes very little energy to maintain good, low stress posture. It’s only when we slouch, lean too far forward, or too far back that we have to engage extra, non-postural muscles to hold our position.

As far as exercise balls go, there’s nothing wrong with using one as your regular “chair” of choice. Most people will prefer the aesthetics and extra adjustability of a well-made office chair, however, so read on.

Gentle Reminders

Now that the base of your seat is at the right height and tilt, you can adjust the back support of the chair. Once you’re sitting in a balanced, tall position, with hips higher than knees, simply adjust the back of the chair until it gently contacts your lumbar area.

The seat back should essentially function as a reminder when you begin to slouch. When you do, your spine will press more firmly into the back of the chair. This additional pressure will serve as your cue to get yourself back into a good position.

The next reminder comes from the armrests. Sitting tall, your shoulders should be relaxed, hanging loosely from your torso. Your elbows should be bent at 90 degrees or more, so that your forearms are angled slightly down from elbow to wrist.

Assuming this position, bring the armrests up so that they gently touch the undersides of your forearms. Once there, if you start to slouch your forearms will rest more firmly on the armrests, and your shoulders will start to sneak up closer to your ears. That’s your wake-up call to get back where you need to be.

The Desk is Next

The base is at the right height. You’re sitting balanced over your pelvis. Your forearms are angled slightly downward. Your wrists are not bent, but are flat and relaxed so that you don’t engage any more of your forearm musculature than is absolutely necessary.

Now, look at your hands. Right where they’re placed is the level that your desk should be. More accurately, this is where your keyboard should be, so your desk should actually be placed an inch or two below that.

Notice that we did not determine what level your desk should be until we got your chair setup exactly as we wanted it. We’re obviously assuming that you have a desk that is capable of having its height adjusted. If not, you have options.

First, you have some room to play with the height of the chair. As long as you keep your hips higher than your knees, and you can tilt the base so that your legs are comfortable, you can raise the chair until your hands rest comfortably at the level of your keyboard.

If your desk is set too high, you may run into a couple of problems. You might not be able to tilt the base of your seat enough to get comfortable. Or, in order to get your hands at the right height you might have to raise the chair so high your feet come off the floor.

In these cases a footstool can be a lifesaver. You can find them at most office supply stores and they’re made for this very reason. Using a footstool your legs will be able to rest comfortably using a chair that is set high enough to get the rest of your body into a good position.

If your chair won’t raise you high enough to get you into the correct position relative to your desk, sometimes a keyboard and mouse tray that slide out from underneath the desk will solve the problem. Consult your local office supply store for options here. If that’s not possible, it’s time to invest in a new chair, desk, or both.

Look Up to Work

The last thing we adjust is the position of your monitor. Don’t skimp on this one. Neck problems that end up causing shoulder, arm, or hand pain are frequently caused by chronically poor head position.

Where do you put it? Right where your eyes go. Place the center of the screen at eye level. You can pick up a monitor riser or even a cantilevered stand to set it at just the right spot. Again, consult your local office supply store. In a pinch, a couple of phone books will also do the trick.

Many “ergonomic guides” that come with computers and monitors recommend placing the top of the screen at eye level. This is too low. Your head will follow your eyes. If your monitor is set on your desk before long you’ll find your neck craning forward so that you can look into the screen.

Finally, make sure the screen is at least a couple of feet from your eyes. Any closer and the constant glare of the screen so close to your face will cause eye strain. Any further and you’ll find yourself bending over your desk to get close enough to the screen to be able to read what is on it.

If you have to use reading glasses or bifocals to see the screen clearly, do yourself a favor and invest in a pair of computer glasses. These are glasses that are designed for computer use.

The entire lens, as opposed to just the bottom half, is devoted to the distance at which you would read from the monitor. This way you’re not constantly tilting your head back and looking down your nose to take care of your daily work.

The Bottom Line

With any setup for a repetitive activity, use your body as a guide. The error often made is in attempting to mold your body to a new task or piece of equipment. This is approaching it backwards.

Always try and position yourself in the most neutral, stress free position and then attempt to adapt your task around it. For this reason it pays to invest in desks and chairs that are as adjustable as possible. This gives you the most freedom to play with different positions and find the one that keeps you at ease.

Investment is an appropriate term here. Anything you’re going to spend hours a day on — for weeks or years at a time — is worth a little extra financially. The return you get in reduced stress, tension, and injury will be well worth it.

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Slow Weigh Down

by Dr. Collins on 09 Feb 2014
in Blood Sugar / Diet and Nutrition / Exercise, Training, and Fitness / Stress / Weight Loss

So here you are, caught in the weight loss abyss somewhere between the the culinary onslaught that was Thanksgiving, and the approaching diet-destroying duo of the Christmas and New Year’s celebrations.

Time for exercise is in short supply. You figure that your best bet is to workout even harder than ever for the little time you have in order to maximize your calorie-burning hours.

Losing weight is all about burning more calories than you take in, right?

Well, no. It’s not quite that simple.

That idea leaves a lot unsaid about the overall effects of exercise on our bodies. There are lots of technical details involving fats, carbohydrates, and number crunching to illustrate why this doesn’t completely add up.

For now, though, I’ll spare you the mumbo-jumbo so we can get right down to understanding how different exercise intensities can impact our ability to get rid of those unwanted pounds. We can also use this knowledge to exercise in a way that helps you become more fit and stay healthy in the process.

The King of Core Muscles

by Dr. Collins on 08 Feb 2014
in Back Pain / Cycling / Exercise, Training, and Fitness

How often have you just finished a good 3-4 hour ride, only to be greeted by a sore, stiff back that isn’t too happy that you’ve decided to move from your usual hunched-over position on the bike? Do you have a hard time standing up after sitting for more than just a few minutes? Does your back occasionally “grab” on you if you bend over to pick up something you dropped? If any of these apply to you, it’s time for you and your psoas muscles to get intimately acquainted.

The psoas (pronounced SO-UHS) is a large muscle, deep in the core of your body. It originates from all of the vertebrae and disks (in between the vertebrae) in your lower back. It inserts deep in your groin area, on the inside of your femur, or thigh bone. It’s a thick muscle. Well developed, it’s about as big around as your lower forearm. This means the psoas has power. Power to move, and power to do damage.

If you’ve ever seen a sailboat mast you’ve probably noticed that the mast doesn’t just stick up out of the boat with no other support. There are usually wires, called “stays”, that run from the mast to the front, back, and sides of the boat to provide stability. Your spine needs similar help. Your back would not be stable if your spine simply stuck straight up from your pelvis with no assistance from other structures. Your psoas muscles provide a great deal of this support. In addition, the psoas is one of your primary hip flexors. This means one of it’s main jobs is to bring your knees closer to your chest. Anytime you’re bent over on the bike, sitting, or performing your best cannonball into the pool, the psoas is potentially in a contracted, or shortened, position.

This is significant for any cyclist. The psoas, just like any other muscle, can cramp or spasm. If you’ve ever had a cramp in your calf or the back of your thigh, you might have noticed that these muscles tend to cramp when the muscle is shortened, not when it’s stretched out. You also probably intuitively stood up to stretch out the muscle to relieve the cramp.

Since the psoas runs down the front of your spine, the only way to really stretch it out is to bend over backwards. Most of us don’t do this very well. So if you happen to be in the middle of a good hill climb, and your psoas decides to go into full-blown spasm, you don’t have an easy remedy! It’s exactly like having a cramp in your calf but not having any way to relieve it.

For anyone with back pain this means the psoas should get a lot of attention. On most people, psoas muscles that aren’t working well are usually (painfully) obvious. A psoas in spasm will not function to full capacity like a healthy, relaxed muscle, and will usually test very weak after a sustained contraction. A bodily “lean” to one side or the other is common. If you can’t stretch this muscle and relieve the cramp yourself, techniques need to be used that help relax the muscle without forcing you into a yoga-like move to bend over backwards.

Adjustments of the lower back and addressing pelvic torque can definitely help calm down the spasm. As with any muscle cramp, dehydration can be a key causative factor. Many of the stories I hear of people who’s back suddenly “grabbed” on them start out with a description of a long day in the saddle.

So the next time you have back pain, while on the saddle or anywhere else, ask yourself a few questions. Are you dehydrated? Have you had other lower back “twinges” or discomfort that might have been your body’s way of telling you that everything wasn’t quite perfect? Do you feel “twisted”, with one hip or shoulder higher than the other? If you can’t clearly answer questions like those and address the problem, get some help to do just that. Your body will thank you!

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The Risk of Training

by Dr. Collins on 07 Feb 2014
in Athletic Injuries / Cycling / Exercise, Training, and Fitness

If you’re training for a race, you probably understand that you will have to push yourself outside of your comfort zone in order to get better. You’ll have to increase your training volume, intensity, or both. You’ll have to add in new exercises or modify others.

However, most of us also understand that though we feel good with a certain level of training, if we add too much too soon at some point we will break down. We know that while we could perhaps handle 50 miles in the saddle, for many of us, attempting 150 would leave us sore, sick, injured, or all of the above.

Sooner or later what we all find out is that there is a risk/benefit ratio to exercise. Almost all forms of exercise have some benefit, but there are none that don’t also carry risk, either short or long term.

Working with both weekend warriors and elite athletes in my office and at the local mega-university, I have the unique perspective of seeing athletes at their worst. That is, I see them when they’re broken. Being in this position rapidly teaches you certain lessons about what kinds of training potentially have the most detrimental effects.

Since it’s much better to be an informed decision maker, let’s run through a short list of high-risk activities. These are things to which you should never let your guard down if you’re interested in maximizing both your training longevity and performance. Here they are, in increasing order of risk…

Eccentric Training

I’m not talking about exercises that make your friends think you’re strange, but rather movements that emphasize eccentric muscular contraction. When you raise a bar bell (or a beer for that matter), the bicep muscle in your arm is shortening while it bears the load. This is a concentric muscular contraction.

When you lower the bar bell, your bicep is lengthening while it bears the load. This is an eccentric muscular contraction. Eccentric muscular contractions are far more damaging to muscle tissue. Some amount of microscopic tearing is thought to happen with eccentric contractions, especially when under significant load.

This is the reason downhill running beats you up far more than going the other way. Explosive, jumping-type movements – what plyometrics are largely based upon – can be risky because of the heavy eccentric load your muscles are put under. This is true not because of the jumping involved, but because of the landing, which is an eccentric activity.

Weight Training

Among athletes, I see a huge number of injuries come from the weight room. Much (though not all) weight work is designed to isolate particular muscles or muscle groups, loading them in a specific, measured fashion, such that they will adapt and respond to a far greater degree than they might otherwise.

While this is arguably a great way to gain strength and fitness, it is a form of load that our bodies don’t generally encounter in nature. Bodies are “designed” for cooperatively combining the action of many muscles at once, to produce complex, multi-joint movements. Loading up a specific muscle without the aid of his neighbors places a higher likelihood on the risk for injury.

High Intensity Training

This one’s a doozy. Increasing training intensity too much at one time is one of the most frequent causes of sickness and injury. How many runners have we all encountered who were doing just fine plodding along at 20-30 miles a week, only to get injured the first time they attempt (usually unsupervised) speedwork?

Intensity needs to be increased in careful, measured doses. When starting out, if you’re having second thoughts about whether you can handle a planned workout, you may be biting off more than you can chew. Never increase volume and intensity simultaneously, and be sure to get guidance from veterans of high intensity work or a good coach before jumping off the deep end.

Poor Technique

This may seem obvious, but poor technique is by far the biggest cause of athletic injuries. Using good technique means performing a movement in a way that doesn’t place joints, ligaments, and muscles in mechanically disadvantaged positions.

Most people understand that complex movements like a golf swing or a power clean in the gym require excellent technique in order to both perform optimally and avoid injury. The not-so-obvious part is that people frequently assume their technique needs no adjustment for relatively more simple movement patterns like a running stride or pedal stroke. This is a dangerous assumption to make.

Adding poor technique to any of the other activities mentioned above creates a true recipe for disaster. Attempting focused eccentric movements, weights, or high intensity training without regard for proper technique is a sure way to end up on the couch for weeks, if not longer.

No matter what your sport, spend the time to develop good technique habits, and regularly seek guidance from those who have the knowledge and willingness to help you learn the best movement patterns.

It should be noted that, with the exception of poor technique, all of the methods mentioned above can be applied carefully and deliberately to achieve excellent fitness gains. However, getting better at an athletic activity, particularly of the endurance variety, is largely about staying healthy long enough to allow prolonged, consistent training uninterrupted by injury or sickness. That is, you have to survive long enough to get good. Keeping your guard up to these common pitfalls will help you do just that.

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Who Am I?

by Dr. Collins on 05 Feb 2014
in Health Care

I was recently having dinner with my father and brother, when my brother made the statement, “It seems like you do a lot more than the average chiropractor. Why is that?”

My father quickly indicated his agreement, curious as to why the things I do are seemingly not associated with many other chiropractors in the world.

While responding to their inquiry, I had a background question of my own running through my consciousness: If my own family isn’t totally clear about what I do, what about the rest of my patients?

There are really two questions that arise out of my father and brother’s inquiry. First, what are chiropractors trained and licensed to do? Second, what do I do that is different from other chiropractors?

In this article I’ll address the first question. I’ll save the second for the next installment of this newsletter.

Let’s start with some thoughts on health care in general.

Conservative vs. Aggressive Health Care

The first piece to understand is that there is conservative health care and there is aggressive health care. By this, I don’t mean one set of doctors who voted for Reagan and another group that happens to be pushy.

What I mean is that there is a full spectrum of care, from the least invasive to the most. From a treatment that is as natural as possible to one that radically alters your existence.

The most invasive care available today, generally speaking, is surgery.

If you think about it, what could possibly be more radical to your body than opening it up and physically altering it in some way. This is why surgery can sometimes bring about the most radical and rapid change for a condition, though it also carries with it the biggest risk.

On the other end of the spectrum would be the most gentle, least invasive treatment a doctor could prescribe to effect an improvement in your health. Minor lifestyle changes, like suggesting that you make a concerted effort to get more sleep, would fall into this category. They carry little to no risk of harm just from undertaking this kind of change.

In between these two extremes is where everything else falls. Dietary changes or adding basic vitamin and mineral supplementation definitely fall on the conservative side, while prescription drugs that alter your body’s natural physiological mechanisms are highly aggressive forms of treatment.

Aggressive treatments are characterized by a higher risk to your health from the treatment itself, usually in exchange for a more rapid or radical change. Conservative care encompasses treatments that are low risk and typically, low expense methods.

In general, it makes much more sense to start with a conservative method that is low cost and low risk, rather than jumping immediately to an aggressive, higher risk form of care.

If you had a weed problem in your back yard would you go straight to hiring a backhoe to completely replace the topsoil, or would you try to put on a pair of gloves and manually remove the offenders first?

And My Doctor?

Given the large number of treatments and procedures that a doctor might choose, what does your doctor do?

That’s largely determined by three things: what a doctor is trained to do, what that doctor is licensed to do, and what that doctor is actually interested in doing.

The first part, training, is governed by the doctor’s education, both in and out of school. The second, licensing, is largely determined by the laws of the state in which the doctor practices. The last part, or what the doctor actually chooses to do, is influenced by the interests and drive of the doctor, as well as real or perceived legal ramifications of performing certain procedures.

For example, an Ob/Gyn (Obstetrician/Gynecologist) was trained in basic examination of the eye while she was in medical school. She is licensed, as a medical doctor, to perform them on her patients. However, you won’t find her performing them on her patients on a regular basis.

This is true for many reasons.

First, this particular doctor most likely specialized in her field because she had an interest in it. Eye exams are not generally part of the routine examination you might receive from an Ob/Gyn, for obvious reasons.

Second, due to her known specialty, the patients that walk in the door of this Ob/Gyn are not typically going to be looking for an eye exam.

Third, our Ob/Gyn might be worried about the potential legal ramifications of taking on the maintenance and care of a patient’s eye health when an ophthalmologist, who specializes in eye care, might find a serious problem that she could miss due to the relative infrequency with which she performs eye exams.

Finally, the financial implications of choosing her specialty are very real indeed. The overhead of simply keeping an office running for a medical doctor can be at amazingly high levels.

If you’re a doctor who has a high-overhead practice, just making it will involve spending a good chunk of your time performing procedures that carry a higher price tag.

What About Chiropractic?

A doctor can also be influenced by the perception the public has about what he is actually trained to do. This happens frequently with chiropractors.

If your patient population thinks that a chiropractor simply “cracks backs and necks”, then most likely every patient that walks through the door will be looking for that service, while those who don’t will stay away.

In reality, chiropractors are trained to do much more.

All chiropractors go through the equivalent of 10 semesters (5 academic years) of training in chiropractic school, not counting undergraduate entrance requirements that essentially mirror a pre-med background.

The education of chiropractors is wide-ranging, extensively covering human anatomy and physiology, pathology (i.e. disease), neurology, hands on therapy techniques, and nutrition.

Generally speaking, the only way chiropractic school differs from medical school is the absence of in depth study of pharmacology — the study of prescription drugs and their effects (though chiropractic education does cover basic principles of pharmacology). In its place, chiropractors get much more study in hands on therapies, nutrition, and rehabilitation.

Chiropractors also receive more training in anatomy and physiology than any other health profession. Chiropractic study covers every joint, muscle, and nerve from head to toe. It covers every organ system from your brain and heart, to your kidneys and gastrointestinal system.

The licensing of chiropractors, like other health professions, is largely determined by the laws of your state. The state of Texas allows a chiropractor to apply a wide range of procedures, including manual therapy techniques, nutritional supplementation, lifestyle prescriptions, and even acupuncture with additional training.

What is excluded from the chiropractic repertoire are drugs and surgery. That is, a chiropractor in Texas is licensed to practice conservative health care.

Why Specialize?

The financial issues affecting other health professions place chiropractic in a unique position.

My malpractice insurance for an entire year is in the low four-figures. MDs typically have premiums that are ten times that amount.

If you combine that with a practice design that does not involve insurance paperwork (other than what the patient chooses to file), my low overhead uniquely places me in a position to spend much more time with each patient, and focus on straightforward, low-cost, conservative measures to improve my patients’ health.

Essentially, this allows me to focus on the entire health of the patient — that is, truly holistic care — in an age where doctors are increasingly shying away from more generalized, “family” practices for higher paying specialty fields.

Being a specialist might work better for the doctor who wants to do well in an age of increasingly high overhead and low insurance reimbursement. Unfortunately, it doesn’t work out so well for the patient, who is in desperate need of a generalist who can make recommendations about their complete health.

Even among doctors that have the ability and training to create a holistic practice, not all choose to follow this model, even other chiropractors. Their reasons are varied.

Lack of interest, the absence of an encouraging mentor, or following conventional practice models are just a few possibilities. It could also be due to the desire to simply have a more straightforward practice.

Honestly, specializing in one thing makes a practice a lot simpler. Patients often present with complaints that frequently affect more than one area in a seemingly unconnected manner. Correlating this varied data in order to diagnose the condition that is truly at the root of their complaint is a much more complicated process.

But the holistic model is one I have embraced as an opportunity afforded to me by a lucky combination of things. There is a large number of people in need. I have a passion for trying to understand the wondrous complexity of the human body. Finally, I’m lucky enough to be in a wonderful profession that allows me the freedom to be an expert in conservative care.

Next time, I’ll address where my interests have taken me in creating my own, unique approach to caring for patients.

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Why You Have An Athletic Injury

by Dr. Collins on 04 Feb 2014
in Athletic Injuries / Back Pain / Exercise, Training, and Fitness / Knee Pain / Neck Pain

It might seem as though I’m being loose with my article titles, but I assure you I’m serious. If we really stop and look at the kind of injury that befalls your average athlete, we’ll find that this kind of impairment afflicts most of us at one time or another.

To start though, we have to know what we’re dealing with. The easy, broad way to define athletic injuries would simply be as an injury an athlete gets.

More specifically, it would be something that impairs the ability of that athlete to perform. The movements athletes perform — running, jumping, throwing, swimming, etc. — are the same ones the non-athletes utilize, only less often and less vigorously.

Some confusion arises over how injuries are diagnosed and classified. For example, the cause of your average case of tendinitis — inflammation of a tendon — is frequently chalked up to “overuse”. What does this mean?

It could certainly be said that an athlete might tend to work a body part a little more than the average Joe. A pro tennis player will exercise and put much more stress on her elbow as part of hundreds of serves in practice and match play.

But this doesn’t explain why she got tendinitis and her teammate, performing the exact same regime, did not.

Two players are as different as their genetics, environment, and training, but beyond this there must be some mechanism by which the tendon of Player “A” became inflamed and that of Player “B” did not.

I suspect the “overuse” classification of athletic injuries is frequently the descriptor added to an inflammatory condition for which the causal factor is unknown.

Evaluate Function, Not Pain

The impairment of the athlete is no different than any ache or pain you might have from time to time.

A wrist that hurts when opening a jar.

A shoulder that stings when you reach for something in the back seat.

A knee that “talks to you” when you climb a flight of stairs.

The ankle that still hurts from time to time after you twisted it years ago.

All of these ailments have a cause that goes beyond the stand-by “getting old” or “the same thing my Dad used to have” explanations.

More information can be garnered — and a more distinct cause perhaps identified — if time is taken to evaluate a person’s function, and not just their pattern of pain. By this I mean looking beyond where it hurts to try and ascertain, for starters, what movements are restricted, how posture has shifted, and what muscles are not working as they should.

The more specifically movements and muscle function can be evaluated, the better we’ll be at isolating the things that need to be addressed to improve function. If function is improved, the pain almost always takes care of itself.

How can I assume that you have an “athletic injury”? From the above it follows that athletic injuries result from impaired function. I haven’t seen a patient walk in the office yet who didn’t have an area that, once thoroughly evaluated, didn’t have some impairment of function.

We never walk around in a perfect state of function. Rather, we’re always in some state of adaptation to the stresses that befall us, both past and present.

The Fix

Whether we experience pain is determined in large part by how well we are able to adapt to a potentially injury-causing stress. Twisting your ankle may or may not hurt depending upon how well you alter the way you walk and carry your body weight differently over knees and hips.

A body will fix a problem by itself — healing a torn muscle, for example — if it has the resources to do so. It will otherwise adapt its function so that that particular muscle is utilized minimally.

Fixing the problem thus depends on isolating the part that isn’t performing normally. That is, find out how function is impaired, and then address the condition that is preventing its restoration.

This is very much like the circuit breaker in your house tripping when you try to flip the switch to turn on the lights in the bedroom. The circuit for the bedroom lights could have blown due to a number of reasons. Faulty wiring, electrical overload, or a short in a particular appliance, to name a few.

Getting the lights back on then requires two things. First, address the problem. Remove the appliance that’s causing a short, for example. Second, reset the circuit. Only by performing both actions will you get the lights back on.

Bodies work similarly, but the circuits are a lot more complex. When seeing patients, the “circuits” I fix every day can require the restoration of alignment with an adjustment to the joint, fascial work around an impaired muscle, or the aid of supplemental nutritional enzymes to help clear out debris and damaged tissue.

As we are indeed holistic individuals, the restoration of function can require that we address the entire spectrum of chemical, structural, and psychological stresses that each of us encounters every day.

For lasting change, however, we must both address the cause of the problem and do whatever is necessary to “reset the circuit”. Anything less is a disservice to you as an athlete in the game of life!

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