The View from Sports Center

How to Rejuvenate Your Legs

As you get older, your muscles get smaller.

There's some disagreement about when "older" happens but just about all the experts agree that after the age of 65, most people will experience shrinking muscles.

And, smaller muscles means less strength, quicker fatigue, less overall ability, and more fat on your body.

One of the reasons this happens is that the blood flow in your legs, for example, slows. This in turn alters how your body uses certain hormones like insulin which in turn alters how your body builds and breaks down muscle. 

I don't know about you but I'm not too thrilled about losing muscle mass. Sure, I can be as vain as the next guy but really, I have a lot of things I like to do, want to do, and I need my muscles to do their job.

Recently researchers have found that muscle building exercise actually age-reverses the blood flow in people of 65 years of age creating blood flow patterns of a 25 year old. The downside to this is that you have to work at it. It's not a pill or a lotion or a chant you repeat during morning meditations. You have to sling some iron around - eventually - and do it for five months, three times a week to produce the changes.

Here are three drills that will help you get started on rejuvenating the legs. To do these, you should be able to squat on both legs without any joint pain (pain in or around the joints) in the back, hip, knee, or ankle.

1. Squat and Freeze: Perform 5 squats without any extra weight. Stop the motion when your knee reaches about 90 degrees. After the 5th squat, hold the squat position for 5 seconds then proceed right into the next series of squats again. Do this cycle 5 times.
2. Split Squat: Stand with one foot out in front of the other - about 12-18 inches. Squat down until your knee reaches about a 90 degree angle then return to the starting position. After 12 repetitions, your muscles should be moderately tired (so, you could possibly do 2-3 more reps). If not, hold a 10 lb dumb bell in one hand and try again. Rest for a minute and repeat two more times.
3. Sumo Squat to 1/2 V: The Sumo Squat is a squat done in a very wide stance - feet beyond shoulder width apart. The 1/2 V refers to a position of the arm. The "V" position is created when you stand and raise both arms up and slightly out to the side: a "V". So, a "1/2 V" is just using one arm. To do this drill, you'll need a dumb bell.
4. 1. Stand holding the dumb bell in one hand. Squat down to about a 90 degree position in the knees - the dumb bell should be between the knees, and upon returning to upright, lift the dumb bell up and out. When you squat down again, lower the dumb bell to the starting position. Use a light weight dumb bell between 3 and 7 lbs and aim for 10 repetitions with a moderate amount of fatigue. Rest 1 minute and repeat two more times.

If you've not exercised in a long time, I would either visit a trainer or therapist and get some coaching first and that's especially true if you have any kind of joint symptoms - aching, stiffness, pain, soreness. The drills are surprisingly difficult even without much weight. If these kinds of drills are new to you, try one set, two days a week with a day or two in between for a couple of weeks and then add another set, etc. Ease into it.

And, by the way, "cardio" won't help you keep your muscle mass. You have to really challenge the muscles using some form of resistance.

Now if I could just find an exercise that would grow a head of hair......

Onward.

Emilie A Wilkes, Anna L Selby, Philip J Atherton, Rekha Patel, Debbie Rankin, Ken Smith, and Michael J Rennie. Blunting of insulin inhibition of proteolysis in legs of older subjects may contribute to age-related sarcopenia. American Journal of Clinical Nutrition, 2009;

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Should You Skip the Ibuprofen Before or During Your Run?

Who wants to hurt?

Especially while you're out on a favorite run.

So, maybe you've heard somewhere or read somewhere that taking Ibuprofen before you run or even during a longer run helps shoo the pain away. If your knees or hips ir back normally hurt when you run, a little Ibuprofen can be like magic. How bad can that be for you? After all, you can buy it in any grocery store or drug store.

As it turns out, pretty bad actually.

Researchers examined the blood of runners who took Ibuprofen before and during a long, endurance race and compared the findings to runners who did not take the drug. They discovered some disturbing things:

1. Biologic markers of inflammation and increased immune system response were higher in the drug group than in runners who had not taken the drug.
2. Signs of mild kidney impairment in the drug group.
3. Low-level endotoxemia, a condition in which bacteria leak from the colon into the bloodstream, was found in the runners who took Ibuprofen.
4. Runners had no more or less pain than the group who did not take the drug.

In addition, Ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs), like Aleve or Motrin, can interfere with the bodies natural healing response. Injuries to tendons, bones, cartilage, and ligaments can take longer to heal and heal less completely with chronic use of NSAIDs.

There's a time and place for NSAIDs though. For acute injuries, pain relief, and short term use, NSAIDs can be helpful and relatively safe (some people still have gastrointestinal side effects). When you're using the drug to allow you to do something like go for a run is where you run into trouble.

Nieman, D. C., D. A. Henson, et al. (2006). "Ibuprofen use, endotoxemia, inflammation, and plasma cytokines during ultramarathon competition." Brain Behav Immun 20(6): 578-84.

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Scientists Discover Cause of Cartilage Degeneration

A

n article here explains a new finding by a group of Scripps Research scientists that points to a loss of a particular protein in the surface layer of articular cartilage. Scientists believe that the loss of this protein leads to a disruption of the cartilage and initiates the degenerative cascade.

New treatments might be developed that would either halt the loss of the protein or initiate development of it but until then, take good care of your joints.

DK

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How Can I Protect My Joints?

A

n email from a reader who asked a great question:

"You stated that cartilage can be strengthened as long as the right load is being used. Does that mean that if I currently have no knee pain, doing body weight squats regularly would be a good way to keep knee cartilage healthy? And if so, do you have any opinions on the debate over depth of squat i.e. partial, 90 degree, full squat?

One of the things, I really like about your site is it's emphasis on joint health. I'm 35 yrs old with a long history of contact sports and a number of thankfully minor injuries. I don't have any obvious joint pain, or problems that I know of. I'm currently trying to figure out the best fitness routine to adopt if my main goal is joint health, range of motion, freedom from pain etc. I've been able to gather a bit by reading your own workouts you've posted, but I'd love to hear more about your thoughts on the best way ensure joint health, range of motion, etc. into the later years of life."

Thank you for your email and questions. I think the last sentence of your email, turned into a question, gets to the heart of the matter. "What can I do to ensure joint health, range of motion, etc., into later years of life?"

I completely understand this one. And, came to understand the importance of joint health, in my self, later than I would have liked. I missed or ignored many early warning signs as so many others do. Pain is only one of the symptoms of joints that needs attention. There are two other things to consider when it comes to the language of joint problems: stiffness and / or aching. And of the two, stiffness seems to be the most insidious. I've met with hundreds of clients who recall feeling a sense of stiffness well before they ever had aching or pain symptoms in their knees and most of them ignored it. I know I had that symptom in my left knee and lower back over thirty years ago and now have to work much more diligently to keep relatively healthy joints.

So, assuming you have no symptoms, there are a few basic requirements for healthy joints (to avoid turning this into a thesis, I've omitted a few things but these are the fundamentals). It's more than whether to do squats or some other drill. Joint health is a lifestyle choice. It's a set of values and beliefs that are expressed in your everyday life. So, with that in mind, here they are:

• Regular movement through out the day and maintain an active lifestyle. Walk much more than you sit. If you work at a computer, use a software program to interrupt you and guide you through some general movements and stretches. Buy a pedometer and shoot for 10,000 steps per day. Joints need to be moved frequently under a variety of loads and movement patterns (which is one of the reasons my training sessions vary). Joints deteriorate over time from disuse or misuse. A sedentary lifestyle, exemplified by fewer than 5000 steps per day, allows the joint surfaces to soften but without any warning. Then, if you decide one day to suddenly become active, after being relatively inactive for years, the joints aren't prepared for the increase in force which sets you up for injury.
• Aerobic exercise at least three days per week for at least thirty minutes. Running is not my first choice when it comes to maintaining healthy joints but, if you've been a regular runner, someone who started early in life and have continued to run, running is ok for you according to the research. But, the key here is consistency. If you've not been running regularly for several years, don't start until you have adequate strength and even then, start with a gradual, beginner's program. I prefer to use elliptical machines, cycles, arc trainers, etc. They create lower compression loads and you can move your joints (hip and knee) through a larger arc of motion which your joints really appreciate.
• Move your joints through their normal and available range of motion - a lot - under low load conditions. If you have established an active lifestyle that includes regular aerobic conditioning, movement, flexibility and strength training, you may not need to perform low load, high volume squats - the low load, high volume choice for the hip, knee, and ankle. However, most people become concerned about their joints when they have had symptoms, an injury or perhaps have someone close to them who has struggled with joint pain. Squats then become a staple for joint health. If you're able to squat on both legs with good form and no symptoms, then start with 50% of your body weight (not by adding 50% to your body weight) and perform squats, stopping the motion between a 90 and 120 degree knee angle, for 15 minutes 1-2 times per week (Sometimes people misunderstand what I mean when I say squat with 50% of your body weight. If you weigh 150 lbs., the force you would use would be no more than 75 lbs.). You can increase the load over time, gradually. I've had several clients work their way up to 70% and even 100% of body weight. An important element of this though is that the squatting should be minimally fatiguing (on a scale of 0 to 10, where 10 means you cannot possibly do one more, a 3 or less). So, if you start with 50% of your body weight and at 5 or 6 minutes notice that your legs feel tired, the load is too heavy. Many people are quite surprised to find that, even though they can perform 20 or 30 full body weight squats (or even above body weight squats), they have to use 20 or 30% of their body weight for the joint conditioning component. That's ok. Use what your body says it can handle and no more. My tool of choice is the Total Gym. I  know some people who have used something similar called a Body Rail. I've not used it so I can't say if it is worth buying or not. But, using a leg press at the gym, which seems like a reasonable thing to do, is risky. The reason is that most of the leg press machines place your body at angles that increase pressure in the lower back. This isn't as much of a concern when you perform 10 or 20 repetitions but when you perform 200 or 300 or more, the cumulative load can create problems for your spine.  Imagine, in your mind, rotating the image (of the seated leg press) 90 degrees to the right. Does that look like something you would want to do 200 or 300 times? A supine leg press is somewhat better, biomechanically speaking, but I've found that the loads in these machines can be highly variable.
  
  •  On the issue of the deep squat (more than 120 degrees where the buttocks strike the calf muscle), I think that's very risky for most people and certainly for joint conditioning it could be injurious. I know trainers, some, advocate "deep" squats. But, you must have exceptional mechanics to pull this off and in terms of muscle strengthening, you don't gain much by moving past about 90 degrees of knee flexion.
  • The partial squat, usually 45 degrees or less, is often used because the load is too great for the knee - even at body weight. This same person, under less than body weight conditions, can usually squat to 90 degrees without symptoms.
• Optimize your biomechanics. In a nutshell, examine your posture both at rest and moving, you may need to get some help with this from a professional, and determine the things you should change and can change and then go about changing them. For example, for the knee, limitations in flexibility at the hip and ankle often create problems for proper force transmission through the knee. Other joints have similar relationships with neighboring body regions (like th cervical spine and thoracic spine and shoulder).
• Keep your body fat within acceptable ranges. Body weight is not the issue. It's how much of your weight is fat and how much is muscle and other lean tissue. Joint problems seem to follow a rise in body fat.
• Train movements; not muscles. Joint problems seem to crop up when people have either not been exercising the entire body routinely or decide to exercise to improve the way they look by isolating body parts. Your body works best when more body parts work together; at the same time.
• Know your strength levels; check your speed. Muscular strength, in particular fast twitch fiber strength, is very important for joint protection. As you age, you will lose fast twitch fiber strength unless you actively train to keep it (and even then, you'll lose some due to changes in hormone levels). Identify your strength for key functions (such as push, pull, squat, lift, reach) and speed (e.g. how many squats can you perform in one minute, how fast can you cover 100 meters). Most trainers and therapists should know how to test these functions.
• Stay well hydrated. Cartilage loves water and uses it to increase its stiffness. Make sure your body has an adequate supply.
• Vitamin supplementation. Controversy exists here and research is thin but vitamin supplementation ( E, C, A, B6, B2, and Selenium) has been shown to reduce anti-oxidative enzymes and development of mechanical osteoarthritis.
• Protein. Make sure you have enough protein in your diet. It's a major building block for repair and growth. Most experts suggest .8 grams of protein / kg of body weight. If you've sustained an injury or you exercise regularly (which you will if you want to protect your joints), protein intake should be between 1 and 2 kg of protein / kg of bodyweight. There's some research that suggests, although controversial, eating too much protein for too long can deplete the bone of calcium so keep your intake in the suggested ranges.
• Pay attention. Be aware. Listen for the first signs of a joint in trouble - stiffness and swelling. You may not hurt at all. If you wake up in the morning and your knee feels stiff, that often means that whatever you're doing (exercise, not exercising, too much exercise, too much sitting, etc), it needs to change. Watch out for these episodes of stiffness and when they begin to repeat with increasing frequency, take action. 

DK

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ShouId I Take Glucosamine and Chondroitin Sulfate?

I

get asked this question a lot. If you have osteoarthritis, you might have heard about these two supplements: Glucosamine and Chondroitin Sulfate. If you've read or listened to any of the mainstream media, you've probably also have heard that neither of these supplements are effective for people with osteoarthritis.

The media latched onto an article published in Arthritis & Rheumatism in 2008 and declared that the supplements were ineffective even though the lead author, Allen Sawitzke, said that the study had significant limitations, like a small sample size, and that the study couldn't determine whether glucosamine and chondroitin are effective for patients with arthritis. Sawitzke also admitted that the study needed a better method for measuring the joint space. Some critics have argued that the method used was not sensitive enough to detect meaningful change.

Here's my suggestion. Chondroitin Sulfate is a disease modifying agent for osteoarthritis. It slows the progression of the disease and deterioration of the joint cartilage. If you have osteoarthritis and have clearance from your doctor (people who have diabetes, are allergic to shellfish or take blood thinners need to visit with their doctor first), you should be taking at least 800 mg of Chondroitin Sulfate for at least two years. This is how long it takes for the supplement to slow the deterioration of the cartilage and the disease modifying effects are independent of symptoms. So, take it even if you feel fine.

DK

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Stephan Reichenbach, Rebekka Sterchi, Martin Scherer, Sven Trelle, Elizabeth Bürgi, Ulrich Bürgi, Paul A. Dieppe, and Peter Jüni Meta-analysis: Chondroitin for Osteoarthritis of the Knee or Hip
Ann Intern Med 2007; 146: 580-590

Michel BA, Stucki G, Frey D, et al. Chondroitins 4 and 6 sulfate in osteoarthritis of the knee: a randomized, controlled trial. Arthritis Rheum 2005 Mar;52(3):779-86

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Running Into The New Year

I

've noticed more people running in my neighborhood lately. People I've not seen before and I'm out walking with my dogs a fair amount and I have a reasonably good memory (except for things like where I put my keys) so I'm thinking that these are folks who are trying to get a jump start on a new year. Get in shape, lose some weight, tone up. Running seems to be the exercise of choice when someone gets the get-in-shape itch.

I'll bet that some of these new runners are going to develop knee pain and some of those will end up with the diagnosis of Runner's Knee and then spend a bunch of time on the Internet searching how to fix it and discover a two common themes in treatment: stretch the IT Band and strengthen the quads.

There's nothing wrong or bad about stretching the hip or strengthening the quads. Making your quads stronger can only help you. But, I don't think you can stretch the IT Band and actually change its' resting length at all. The reason I think this is that the IT Band has an inherent structural stiffness of about 100 lbs/ inch*. You might be able to alter the length of the muscle attached to it but the band itself is really tough (which is why it's sometimes used to augment ACL reconstructions).

So, if stretching the IT Band doesn't actually happen then why do so many people do it and claim it's effective?

Stretching or massaging or using deep pressure or any other manual technique may increase range of motion of the hip but that doesn't mean that the cause of the increase is that your IT Band is longer. It just means you have more motion. The IT Band is the tendon of the "pelvic deltoid" muscle - the tensor fascia latae and gluteal muscles. Since the IT Band has such high tensile strength, the improvements in motion are from changes in the muscle tone or tension. It relaxes.

When I finally figured this out, I felt liberated. I no longer had to study and practice hours trying to master specific hand placements and highly subtle techniques. I had PT instructors / mentors, who would look at my hand placements on a patient's leg and say, "No, no, no. Not there. Here," and then move my hands about an inch one way or the other. It made no sense to me. Bottom line - your brain doesn't know anything about technique. Your brain could care less if you're using Myofascial Release or Rolfing or Deep Friction or a foam roller. Your brain responds to input; intensity, frequency, duration. When you rub or tug or push or pull on the tissue, your brain processes the input and decides to release pain relieving chemicals or reduce the muscle tone or both. The result is you suddenly have more motion.

So, you might be wondering if I'm just in a tizzy about nothing. Who cares? Here's why. The goal is to increase motion in the hip and if you're at all like me,  I prefer to get there as easily and painlessly as possible. So, I'm suggesting that rather than stretch the IT Band, which is bit like trying to stretch a brick, why not either use massage or some other manual technique to the hip deltoid muscles or even better, use exercise to improve the mobility of the hip? If there is more than one way to the goal, why choose the hard way?

As for running into the new year, my advice is to get fit to run rather than run to get fit. It generally works out better in the long run (I just couldn't avoid that one but it's true).

Doug Kelsey

* Birnbaum, K., C. H. Siebert, et al. (2004). "Anatomical and biomechanical investigations of the iliotibial tract." Surg Radiol Anat 26(6): 433-46.

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Letter to The Editor

I

hardly ever read this magazine, "Advance for Physical Therapists and PT Assistants" since it rarely has articles that I find interesting. But, this one caught my eye, "No More Knee Pain" so I decided to dive in.

What I discovered is that state of the art physical therapy for osteoarthritis of the knee is to actually not address the primary issue, the osteoarthritis, but rather focus on the effects of OA - muscle weakness and alterations in how you walk. That seems to me like focusing on shortness of breath from walking when you have heart disease. Why not go to the source, if at all possible, and alter the disease process?

So, I had to send a letter to the editor. Below is what I sent. If I hear back from someone, I'll post it.

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To Whom it may Concern,

I am writing in response to an article that appeared in the December 15, 2008 edition of Advance for Physical Therapists and PT Assistants entitled, "No More Knee Pain." and would like to offer a different perspective on the treatment of people with osteoarthritis of the knee.

The article is quite supportive of the use of physical therapy in the treatment of osteoarthritis of the knee from the perspective of strengthening muscle and correcting gait mechanics based on a recently published article in the New England Journal of Medicine that supports physical therapy as an effective non-surgical treatment. In the article, Christopher Powers, PhD, PT, states, "Physical therapy can't cure osteoarthritis. The best thing PT can do is keep the muscles around the knee strong and work on correcting abnormal gait mechanics that may be putting extra stress and strain across the knee joint."

And according to Gregory Masiko, MSPT, "...once OA changes have started, there is no turning back unless there is a reconstruction of the bone surface with total joint implants. A treating PT must tell patients that they are not affecting the arthritic changes within the knee directly, but instead are focusing on tissue that both supports and governs motion at the joint."

I agree that increasing muscle strength and correcting gait mechanics are important elements of a comprehensive rehab program for a person with osteoarthritis of the knee. But, I disagree that interventions employed by physical therapists do nothing to alter the disease process and that once osteoarthritis is present, that there is nothing left for a patient to do but hope that muscle strengthening will alleviate pain and improve function.

When a patient has a swollen, aching, painful knee that prevents them from enjoying life and we, as physical therapists, employ interventions to alleviate the symptoms and restore function, we are effecting a form of a cure according to the New Oxford American Dictionary.

Cure: relieve (a person or animal) of the symptoms of a disease or condition

But, we can go beyond just relief of symptoms. We can alter the physiology of the joint, improve overall joint health, and change a person's life forever.

Physical therapists who use quad sets (or isometric contraction of the quadriceps muscles in a non-weight bearing position) increase the molecular weight of synovial fluid which is, in fact, altering the disease process(1). Synovial fluid with a greater molecular weight improves lubrication and load protection in the joint. Certain exercises that employ low to moderate compressive loads can improve the strength of cartilage which effectively arrest the progression of the disease (2).

Although thus far, we cannot change the presence of bone spurs or regions of exposed bone, that does not mean that we cannot have a substantial impact on a patient's joint health prior to the onset of those conditions. In fact, if we do not alter the biochemistry of the joint, we'll have little success in strengthening muscle due to arthrogenous inhibition (3).

By knowing how exercise shifts the biochemistry of the joint and how to use exercise to improve the health of the joint, physical therapists offer tremendous healing potential to patients. We can do more than strengthen muscles and alter mechanics.


Sincerely,

Doug Kelsey, PT, PhD

1. Miyaguchi, M., A. Kobayashi, et al. (2003). "Biochemical change in joint fluid after isometric quadriceps exercise for patients with osteoarthritis of the knee." Osteoarthritis Cartilage 11(4): 252-9.

2. Roos, E. M. and L. Dahlberg (2005). "Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage: a four-month, randomized, controlled trial in patients at risk of osteoarthritis." Arthritis Rheum 52(11): 3507-14.

3. Hurley, M. and D. Newham (1993). "The influence of arthrogenous muscle inhibition on quadriceps rehabilitation of patients with early, unilateral osteoarthritic knees." Br J Rheumatol 32(2): 127-31.

How Much Strength Do You Need to Run?

I jogged about 1/2 mile the other day on a treadmill. It's been a while since I've done that. It might seem short to you but to me it was like completing a 10K. I felt great.

And, then I thought, "Do I have the strength to do this? Should I be doing this?"

There isn't any research, that I know of, that suggests exactly how much muscle strength you need to jog. And, really, the issue is less about muscle strength than it is about joint strength. During my 1/2 mile jog, each foot hit the ground about 200 times. My joints have to absorb at least twice my body weight (it can get up to 4 times body weight depending on your speed and stride length) with each step which is about 430 lbs of force. That's 86 tons of force for 1/2 mile. Imagine what a 10k produces.

You do need muscle strength though to help you dissipate the force. Here are a few simple screening tests you can do on your self before you start jogging (or even if you are already jogging):

1. Can you squat on one leg to a knee angle of 70 degrees (two pillows in a chair will give you about that angle) back up thirty times with good form and no pain? Squat down until you feel your rear end touch the pillows and then stand up.
2. Can you stand on one leg for at least 30 seconds?
3. When you stand on one leg, do your hips stay level?

If you can't at least do the above, you may want to do some work before you take up jogging.

For me, I think I'll stick to half a mile for now.

Make today count.
Doug Kelsey