Brian Schiff’s Blog

So, I recently blogged on platelet rich plasma (PRP).  I wanted to provide you with the latest up to date info on this procedure in regard to chronic tendinitis.  Many people suffer from lateral epicondylitis (tennis elbow).  This is a condition that affects the extensor tendons in the elbow.  Most experts link tendon injuries to hypovascularity (not enough blood flow) and repetitive micro-trauma thereby resulting in localized weakness and degeneration over time.

This may lead to eventual rupture but no one can predict that for sure.  Using PRP would hypothetically reverse the effects of chronic tendinopathy while stimulating healing at a microscopic level by initiating revascularization.  The info and data for this post was in large part taken from the American Journal of Sports Medicine (Nov. 09).

It is important to keep in mind if you are dealing with tennis elbow to understand the difference between acute injury and chronic pain.  Physiologically, healing enters the chronic phase in 22 days post injury.  However, from a clinical perspective, a physician may not consider elbow tendinitis chronic until after 3 months or more in some cases.  While PRP has shown positive results in several small case studies, the abundance of solid research is still lacking or too small to draw finite conclusions as to its efficacy.

With that said, let me share some data for people who were treated for tennis elbow with PRP:

• Mishra & Pavelko treated 20 patients out of a sample of 140 with elbow pain who met their inclusion criteria.  Of those 20, 15 were given PRP and 5 served as controls receiving only local anesthetic injections.  The PRP group noted a 60% improvement at 8 weeks, 81% at 6 months and 93% at the final follow-up (range b/w 12 and 38 months).  However, 3 of the 5 controls withdrew from the study early to seek other treatment which means the data can only be drawn from the PRP group.  Although flawed with a small group and attrition in the control group, this study was prospective and did include a control group.

What does this mean?  Well, if you have ever suffered from lateral epicondylitis or worked with those that have, you know how difficult this condition can be to resolve.  I know several people that opted for surgery to end the pain.  Conservative treatment often consists of ice, rest, stretching. strengthening and cross fiber massage.  Some use a Band-it brace and acupuncture as well.  In the end, it can be down right debilitating.

PRP may provide a better answer, but more research and larger trials are needed to confirm the overall efficacy of it.  If you are a chronic sufferer though, you may want to seek out an orthopedist who is proficient in this and take a look.  Aside from tendinitis, the effects on muscle strain, ligament tears and bone are also being studied.  High level athletes are using PRP to get back to play faster as one unpublished study with professional soccer players suffering grade II MCL injuries reports a 27% faster return to play after injury compared to controls when injected with PRP within 72 hours of the injury.

In the end, the optimal dosage and use of PRP has yet to be defined.  But it may certainly signal a new era of treatment of soft tissue injuries and speed the recovery from such injuries.

According to research, more than 70% of people in the US will experience at least one episode of low back pain (LBP) in their life.  What is known about LBP and jogging?  Keep in mind running is an extension activity in the spine.  It also involves obvious repetitive compression/loading with ground impact.

A recent study in the Journal of Athletic Training (Sept./Oct. 2009) looked at the impact of lumbar paraspinal muscle fatigue and postural adjustments seen in running.  Poor lumbar extension endurance has been linked to increased risk for developing LBP.  In this study, researches looked at 25 recreationally active participants with a history of recurrent episodes of LBP and 25 healthy controls.

The testing process included:

1. 5 minute warm-up on the treadmill
2. 60 seconds of treadmill jogging at self selected pace
3. 1 set of fatiguing isometric lumbar extension exercise
4. Another 60 second treadmill jog at the same speed

For your reference, the fatiguing lumbar exercise consisted of repeated cycles of 10 second, gravity resisted isometric contractions followed by a 10 second rest on a lumber hyper extension chair.  So, what did the results show?

In a nutshell, those with a history of recurrent LBP showed much less postural adjustment with the muscle fatigue compared to their healthy counterparts.  The healthy subjects tended to exhibit a more forward trunk lean (1.1 degrees or less lumbar lordosis) and increase lateral bend during jogging gait.

On the flip side, those with recurrent LBP, they tended to stay more upright (0.2 degrees of additional lean on average).  The authors feel this may indicate a coping mechanism due to core instability and a way to effectively stabilize the spine.    Increased trunk lean would increase forces on the spine and intervertebral disc.  The lack of change in the population with LBP may help explain excessive fatigue in the muscles that support the spine, pelvis and hips.

So what does this mean for those who have LBP?  The postural change, or rather lack thereof, may be an Aha moment in regard to the need for improved core training for runners and athletes.  It should also indicate that long term running or athletic competitions may increase the risk for more frequent LBP or a greater back injury. 

There are three big takeaway messages here:

1. Include low back extension endurance training in your workouts
2. Integrate appropriate core exercises (planks, side planks, 3 dimensional exercise) to improve strength and stability of the hips, pelvis and spine
3. Get professional evaluation and training from a knowledgeable fitness pro if you have LBP

Well, it is just days before I embark on my 3rd half marathon.  Just one short run to go.  And no, I am not suffering from shin splints (lol).  But as I approach the Columbus Half Marathon on 10/18, I am reminded about all the patients and clients I see who are in some way affected by shin splints.

Shin splints, more commonly referred to as medial tibial stress syndrome (MTSS) in medical circles, plague many runners, walkers and athletes.  So, what is a shin splint?  People often report pain and tenderness along the outer or innermost portion of the lower leg.  Anterior shin splints affect the anterior tibialis muscle and are seen more commonly (my experience) in people who walk rapidly for the first time or do several hills without training for them.  I saw a camper of mine who runs regularly develop shin splints doing a 5K walk and trying to walk fast and keep up with another camper.  She never has had shin splints in years of running.

Posterior shin splints are probably more widely seen among most runners.  They tend to be more common in females as well.  The source of pain was commonly linked to the posterior tibialis muscle, but is now thought to be along the origin of the medial soleus muscle and its deep fascial insertion.  Hmmm….. the soleus – now if you have read my earlier posts, that is a muscle I personally know a thing or two about when it comes to injury.

 What are some causes of shin splints?

• Tight hamstrings (affects closed chain biomechanics)
• High or low arches (twice the injury incidence as those with normal arch height)
• Faulty training surfaces (uneven sidewalks and asphalt can be brutal)
• Improper training technique or progression (this is a biggie for sure)
• Muscular imbalances (weak hips anyone?)
• Excessive foot pronation (flattens out or rolls in too much during gait)
• Worn out or improperly fitted/cushioned footwear

What else may cause such pain?  It may be a good idea to see a medical professional for diagnostic testing to rule out a stress fracture (often severe pin point pain along the medial tibia), exercise-induced compartment syndrome, and a possible popliteal artery entrapment (Tolbert and Binkley – NSCA Journal 2009). 

Outdoor boot camps and running are gaining in popularity these days.  Both activities are great for weight loss but also carry a higher risk of shin splints for participants, especially overweight women.  Proper warm-up, selective footwear and stretching are great strategies to reduce or prevent injury.

If you have been affected already and are seeking help, I suggest the following:

1. Relative or absolute rest from the offending activity
2. Ice the affected area daily (2-3x/day)
3. Standing hamstring stretch (flat back) with and without foot rotation in and out – hold for 20-30 seconds in each position (repeat twice)
4. Calf stretching on a step – knee straight – hold for 20-30 seconds (repeat twice)
5. Soleus stretching ona  step (knee slightly bent) – hold for 20-30 seconds (repeat twice)
6. Single leg calf raises to strengthen the posterior tibialis muscle (once able to do pain free) Perform 2-3 sets of 10-15 reps
7. Single leg balance on a slightly bent knee – perform 2 sets of 30 seconds without touching the other leg down (advance to eyes closed for more difficulty)

In the end, combine prevention with sound footwear and a proper training progression and you will have no trouble at all with shin splints.  At the first sign of pain, step back and evaluate if you need to adjust your training as trying to go through it will not make things better.  Happy training all!

Since publishing my rotator cuff manual over 4 years ago, I have received emails from all over the world with shoulder related lifting questions.  Invariably, I discover that many shoulder injuries are simply caused by repetitive micro-trauma in the weight room.

What does this mean?  In effect, it is like taking sand paper and rubbing it over your rotator cuff day in and day out for weeks, months and years until you either create tendinitis or wear a small hole in it.  Exercises that often get people in trouble are bench press, dips, flies, lateral dumbbell raises, and military press to name a few.  I show modifications for all these in my book.

In my shoulder rehab programs, I have always advocated front lat pull downs.  Why?  Simply because I can strengthen the posterior chain muscles, improve posture and activate scapular stabilizer muscles while encouraging retraction and downward rotation of the shoulder blade.  These are necessary things to balance the shoulder.

Some experts and customers question this technique from time to time because they disagree with taking the arm above shoulder height during periods of inflammation.  I say this  varies from person to person.  I have worked with over 10,000 people and can tell you there is never one certainty among symptoms and response to exercise.  With that said, I do not want people to exercise through pain.

To that end, I offer a modified version of the pat pull down to accomplish a similar movement.  The straight arm lat pull will effectively target the same things when done properly.  I have included  a video below showing the technique with a traditional straight bar on a pulley as well as with resistance tubing.

The key points to remember are these:

1. Begin at or below shoulder height
2. Keep the knees slightly bent at all times
3. Maintain a tight core (contract abdominals throughout)
4. Keep the elbows straight at all times
5. Focus on pulling the shoulder blades closer together on the pulling motion
6. Return to the start position under control to avoid momentum taking over
7. Breathe out on the way down and in on the way up

I have found this to be an excellent alternative for those unable to continue with traditional lat pull downs during the course of a shoulder injury or rehab.  It is 100% safe.  The only precaution would be not going forcefully past the hips with the tubing pulls for those with anterior shoulder instability or a known labral tear.  This is not an issue with the cable pull as the bar stops prior to this point.

So, one of the newest treatments being touted in the sports medicine arena is platelet rich plasma (PRP) therapy.  What is this exactly?  It is not an easy thing to explain in plain terms, but here goes my best attempt.

Platelets help the repair process in the body as they contain growth factors like platelet derived growth factor (PDGF), transforming growth factor (TGF)-ß, insulin-like growth factor (IGF) and fibroblast growth factor (FGF) to name a few.  Upon activation, these factors are released and sent to aid the injured site in healing.  In this therapy approach, a centrifuge is used to increase concentration the concentration of platelets.  PRP has up to 8x the concentration of platelets that whole blood does.

The PRP is then usually injected into the injury site.  This is commonly being used to treat ligament sprains such as an MCL sprain in soccer players.  A recent study was released in the American Journal of Sports Medicine in March 2009 in regard to the effects fo PRP on muscle strains.  Muscle strains are largely considered the primary injury in sports medicine today (think about hamstrings, quadriceps, groin and calf strains to name a few).

Keep in mind muscle injuries typically occur when the muscle is lengthening under tension (eccentric contraction).  Why so?  In eccentric contractions the muscle force produced is approximately twice that of a maximal isometric contraction (max muscle force against static resistance without motion).

In this study, researchers looked at rats and induced a muscle injury to the TA (tibialis anterior muscle) in one of two ways: Group A underwent a single eccentric (lengthening) injury over a 90 degree arc of motion, while Group B underwent 45 smaller strains over a 60 degree arc to simulate more of a chronic muscle strain as opposed to an acute injury in Group A.

To summarize the results, researchers found that the PRP had little effect on Group A other than to noticeably affect force production in a positive way on day 3 post-injury.  They are unsure if this is simply due to reduced inflammation (PRP should help with this).  Otherwise, full force production with the single acute strain was back in 7 days relative to pre-injury levels whether using PRP or not.  However, in the repetitive or chronic strain group (group B) the PRP had significantly positive effects at day 7 and 14 and led to a faster overall recovery.

Does this mean we should use PRP on all muscle strains??  Not so fast.  What is clear are that injuries in need of myogenesis (muscle rebuilding) are better candidates for this therapy.  The tricky part is the great degree of variability in muscle strains and determining if the science is transferable from the rat to human model.  In the end, the treatment is promising as there appear to be no harmful side effects, but further research will be needed to validate the impact on healing tendons and muscles alike.

Also keep in mind that progressively rehabbing the injured part with systematic eccentric loading to restore the tissues’ threshold to stress is necessary to accurately gage response to functional mechanical loads.  My hope is that this procedure will be used in conjunction with rehab to speed healing and get athletes back on the field faster.  Its greatest use may come in dealing with chronic tendinitis or partial tears.  Only time will tell, so stay tuned.