Foot Detox Blog

Q: How is spinal stenosis different in the upper back and the lower back?

The principles are similar but there is an additional factor of concern, meaning when we go back to the anatomy lecture, there’s that one additional structure that runs through that central canal that is more important than any other nerve and that’s the spinal cord. On one end of the spectrum the key component is to make sure that spinal stenosis does not going to  point where it is affecting the spinal cord, it starts causing issues with balance, with bowel and your bladder. Having said that the idea in principle is very similar when we were talking about equating issues with the neck and the shoulders versus your back and your hip flexibility. We see very commonly, we share patients quite a bit, that have issues of both the neck and the shoulder and they’re tough nuts to crack because you got to address them both together. The idea is that you can have rotator cuff tear and a little bit of a quote unquote, pinched nerve coming from your neck and one influences the other and biomechanically you need to address both. But which do you address first? Is there a surgical repair that needs to be done on that shoulder as you keep putting pressure on your neck? Or does the neck need to calm down and then you can do a rehabilitation program that addresses both together?

Q: What is that about sleeping on the side that is not good?

Not that it’s not good. It’s just when we lie on our side we have a tendency to kind of curl up in a fetal position and in fetal position you are bringing your knees closer to your chest and that has the same principle of sitting in a chair where the muscles, the hip flexors can tighten down through the night. Now people ask me all the time “What position is best one to sleep in? What kind of pillow should I get? Should I spend $9000 on a [inaudible]?” And I’m like “Are you doing your exercises? Why don’t you start there?” But the idea is this, you want to try and sleep comfortably. Don’t try and force yourself into a position because that’s the right one for you. But there’s certain things to think about and the bottom line is that when we’re talking about the neck, you want to be in relatively neutral position. The pillow, if you’re a side liner, if you think about it needs to be a little bit bigger in order to keep you in a neutral position versus if you’re lying on your back you need a relatively smaller pillow to keep you in a central posture position. The back itself is different. Nothing is good about sleeping on your stomach. That is the only [inaudible] out of all of this. I used to love to sleep on the stomach and it’s just not good.  But the idea is that when you’re sleeping on your side you can have a tendency to get those hip flexors a little bit tight. That’s kind of an issue.

Q: How much calcium is recommended for an adult male?

It’s the same dosage for men and women. Its’ a 1200 to 1500mg a day of calcium and there’s basically two forms: calcium carbonate also known as OsCal and calcium citrate also known as Citracal. The calcium citrate is easier to digest and tends to produce less gas, which I can tell you from personal experience as we get older, is a good thing. What I tell patients is go to the drug store and find an OsCal or Citracal and right next to it will be the store brand which is just as good and costs half as much. 1500mg of calcium a day and 800 units of vitamin D.

One thing that I was told, maybe you can [inaudible] on this, is in my understanding and I’m no osteoporosis expert, but I understand our gut can’t absorb more than 500 or 600 of the calcium in one sitting? You actually need to split it up throughout the day?

It is better to split it up, to do it that way. Unfortunately most of us have a hard time remembering to take something more than once a day but from a physiological point of view, yes, it’s better to split it up.

Q: Do pillow wedges or support braces help relieve night back pain and discomfort?

Yes, so here’s the thing today, you know, I do tell patients to get relief from their back symptoms to sometimes do that. I think that’s more to get things to calm down in the acute stage when you’re experiencing a flare. But in general, once again, you don’t want to be doing that every night because the idea and the component is the same. You are facilitating those flexibility issues, such that then during the days as soon as you wake up and start to stand up those muscles have been tightened down all night long. But it does, the same principle of “Oh, my back’s bothering me let’s go sit down.” And it opens up that canal. So that’s why you can get through relief that you get. Less pressure’s put through the spine when you’re in that position.

Q: When confronted with a sport’s related injury…would you recommend heat or ice?

Usually from my experience, acute injuries, when you’ve just hurt something, ice is always the answer. 3 days of ice is pretty standard. Even after you’ve done running and something’s sore, ice is an anti-inflammatory and analgesic, it means it decreases the swelling plus it makes it feel better. Heat generates blood flow, swelling. It can actually make thing stiffen and hurt more. Heat is sometimes more chronic lower back kind of thing. Dr Kooch can answer about that but in general I almost always universally say that if it’s hurting, I go with ice.

I never go with heath, with one exception, prior to exercise. You’re trying to relax the muscle, get things to loosen up a little bit, so that you can do the exercise but I feel the same way. The literature and this is where the problem is, and why you’re asking the question because you might talk to and get 3 doctors to say ice and 3 doctors to say heat. My principle is the same, we’re trying to reduce inflammation and ice is a natural anti-inflammatory. To complement the deduction they were trying to achieve with anti-inflammatories, I stick with ice. In general I leave any heat application to whatever therapy I’m getting a patient into whether it’s chiro initially or a physical therapy.  Targeting that area for a purpose then always follow with ice after wards.

Q: Is there a fitness program or machine that would work best to keep me in shape?

It’s between your ears. It’s educating you about what your body needs. I want you to understand what your problem is. Where is your problem? Where your flexibility issues are? Where are your strength issues? When you go into a gym, you already have a basic routine that you can do without a lot of equipment. But then there’s a lot of equipment that’s out there. There’s not just one piece of equipment that can take care of all your problems. Each of these pieces of equipment have a different, you know goal. The idea is that if you understand the principle of what you’re trying to achieve to reach your goal, you can use that equipment whatever way you need it. In other words, if you understand that you should be thinking about postural awareness during a certain activity, then if you are keeping your postures correct, then you’re safe and you’re actually building up the muscles the right way. I always use the analogy of wading into the shallow end. You don’t just go into a new gym and try every piece of equipment in the place. It’s what happens with Curves.  Not that I have anything against Curves but you’re kind of forced to do x, y and z instead of your body telling you what you should do.

I like Curves because we get a lot of patients from Curves. Zumba too. You probably want to do activities that are lower impact. You are going to be better on perhaps an exercise bicycle, or an elliptical, or a Nordic track than a treadmill. If you’re going to use a treadmill you want to go low and slow rather than crank up the elevation. If you’re going to use a weight type machine, just because you could bench-press 400 pounds 20 years ago, that’s probably not where you need to start. You need to start very low and go up in maybe 10% increments every couple of weeks. And then you can avoid having to see one of us.

Cross training is important too. Don’t just fall in love with one machine. [inaudible] that’s all you do. You got to cross train and I think exercise physiology has changed a lot since the days of arm curls and dumbbells and light presses. Now I think things are a lot more core strength [inaudible] that’s even more important and that has a lot to do with a lot of cross training and not doing the same thing over and over.  That goes not only for the aging athlete but then year olds that we see constantly that decided that soccer is their sport at ten and all they do is play soccer 24 hours a day, 365 a year. That’s a whole other topic for a whole other group but it has to do with the same idea of cross training and not doing the same sport or the same activity as your only exercise.

Q: Is there a test to detect what joint needs to be addressed first?

I think any of us has enough training and enough know how on an initial evaluation. Go through a reasonable checklist of the areas where the problems are and even based on just the history trying to determine “Hey listen, let’s start picking [inaudible] in this area first” because of a concern stand point. Really, that’s the key thing. It’s from a medical stand point. What area is of greatest medical concern? If you have just back pain, quote unquote, just back pain as we’ve talked about, then the nerves are not involved. But your arm is not able to lift up above this area. Obviously your shoulder is going to be of more concern because you might have torn a rotator cuff. The idea is that any of us should be able to go through a reasonable checklist to try to determine, with you, about the right course of treatment. The idea is that if there’s a back issue, these guys will send them to me. If there is an issue with a shoulder or knee, I send them back to these guys.

Q: Kettle bells for a person that needs to build up their back and stomach muscles. They are bad?

It depends on how you’re doing it and how much you do it. Things like that are difficult because it’s really how you do things more so than what you do. In other words, additional resistance, if I understand what a kettle bell is [inaudible]. The idea is that additional resistance [inaudible] in  lot of the exercises you can do you don’t even need to use additional equipment like that to kind of get the same results. It’ll be safer.

Q: Is a treadmill better than walking outside?

I would actually say that a treadmill is better because they usually go with padding and so it’s going to absorb a little bit of the impact. Whereas outdoor walking we do that most of the time on pavement which absorbs no impact. The other advantage of a treadmill is, if 10 minutes into your workout you’re having pain if you want to stop, you’re fine. If you’re outdoors and you’ve decided you are going to do a 2 mile walk, and 10 minutes out you realize you have to turn around and go back home, you’ve got another 10 minutes to do that. I think that a treadmill is a more controlled environment and is more environmentally controlled in terms of temperature.

If you do the grades you are increasing the stress on the knee, particularly that patellofemoral joint that I’ve talked about which is more important in women. Lower elevation, you’re better off.

Q: Free-weights versus machines?

It’s the same type of principle as far as the kettle bells are concerned. I’m a big advocate of trying to do activities and exercises that don’t involve even you having to go to the gym, using your own body from resistance standpoint. In general, there’s distinct advantages to each of them and disadvantages to each of them. Free weights in general I like them because they are free weights and the idea is that you can move and do whatever you want to do using those weights and there’s certain amount of balance in what we call proprioception that we didn’t even talk about which is a huge issue when we’re talking about aging population. Strength is why we lose battles. If you don’t use it you lose it. The free weights can be an avenue to address that. Now, it can get you into some problems if you’re doing too much or you lose your balance. And that equipment, you’re usually sitting down and you’re safer sometimes by doing so. You lose some from that proprioceptive balance stand point but there’s a safety factor that is not replaceable.

Q: Stop the running, start jogging or start to walk? Is it all functionality?

There’s really no good studies that say that runners let’s say get more arthritis than non-runners. I think you listen to your body. Instead of running marathons maybe you cut down to half marathons or just have a slower pace. There’s not a hard and fast, “At 50 you can run, at 60 you can jog, at 70 you should be walking.” If you have been a runner, don’t give it up. If at 70 you decide you want to run, maybe you ought to rethink that.

Q: When should I ask my doctor about physical therapy?

It’s hard to individualize these things because, we both talked about it, if you have meniscus tear and nothing else, no arthritis…[inaudible] That’s a difficult answer for us to give without treating he whole person. Arthritis pain overlaps with the meniscus pain. Sometimes you can get meniscus pain better with certain procedures and arthritis pain with other things. Pretty hard to individualize on which to go. Therapy is never a bad thing. Therapy is always good for multitude of reasons. It gets you moving and stronger and things more flexible but then again therapy isn’t the answer for every problem either.

Thanks everybody.  

They can’t dampen the forces enough and then the forces come up through the spine and that’s what creates degenerative changes or the injury. Component number 3. In order to understand what happens to the aging spine, we need to know what happens to young, healthy spine and when injury starts to occur and identifying patients before that actual injury occurs. The spine itself is under forces. We’ve decided that. But what ends up happening is that a number of things start happening after we grow up a little bit and aren’t doing sports on a day to day basis. When we’re young and we’re in high school, we’re playing sports every day or we’re out in the back yard, everybody’s active and muscles are strong and flexible and you really don’t care what you’re doing and you injure yourself. The idea is that we get older and we start getting a job, we got other priorities, we got families. And the idea is that our activity level starts to go down. We start working out then just on weekends, we still think that we can run marathons or play taekwondo and you start injuring knees like me, things like that. The idea is that as a result of that you start getting aches and pains. Those aches and pains are little bit of a warning sign that certain things are happening. In general, when it’s just back pain, most of the time in the initial phases here, it’s an injury to the muscles or the ligaments and you get over it. You wait a few days, you don’t even see a doctor usually and it just goes away. You initially have a contribution of the muscles and ligaments injury. But then two other things start happening and they are, you start to get weakness of the muscles that are surrounding the spine. Cause again, if you don’t use it, you lose it. You generate forces, walk around all day, well, what’s generating the forces? Your legs. Your legs stay relatively strong as your activity level goes down. Those muscles in your legs stay strong, the weakness in your core creates the forces now instead of generating from your core muscles out to generate your power and forces during an exercise activity, and now the muscles in your legs are generating forces and causing further and further damage to your spine. This is core. Decrease meaning strength. And then your lower extremities no change in strength or minimum. The last component though is flexibility.

I cannot stress that one enough. The idea is that, especially when you’re an athlete, you use a lot of muscles and especially with running one of the most strong muscles that you rely upon for your exercise and activity are your hamstrings, those muscles in the back of your thighs. And as your activity level goes down those muscles get really, really tight. And they are not very flexible anymore. The idea is that if you’re going back to the principle of the spine now, how does that influence it? The idea is that if you’re moving and bending forward to do any type of activity, whatever it is, and your hips are not now moving, and you’re kind of stuck, then what do you move? Your back. And that starts putting additional pressure where? On that front joint being the disk. That’s pretty important to understand. Again, if you’re not moving through the hip which is the next joint below the spine, then it starts influencing your spine. If the hamstrings are not letting you bend over at the hips and they’re stuck, they you’re going to bend at the waist. What ends up happening is that disk, you start pushing…putting pressure through that jelly donut, the jelly squirts out. Anybody know what’s that called? Herniation. The disk herniates. That hurts but you’re young, you survive, keep going, you don’t go see the doctor. 5 years down the road you’re feeling a little bit better. That jelly itself probably stays a little bit there but essentially the jelly on the inside of the jelly donut starts to dry up a little bit. Now this disk herniation, HNP which is a herniated nucleus pulposus, is the big issue. That thing heals up. Now what we’re dealing with here is repeated episodes that are continually getting worse, either severity wise or just biomechanically. And they start taking toll, and toll and toll again. Yeah, you continue to get over it but each episode is taking its toll. So now we’re going to go down to the aging spine. Now what’s happening here? That disk kind of remodels a little bit and although that jelly starts to reabsorb a little bit, the disk itself, just because of repeated forces through it starts to do  this thing where it kind of starts to look more like a pancake rather than a jelly donut. Starts to flatten out. As the result of that jelly starting to dry up just because of age, then it’s not dampening the forces that are going through that [inaudible]. So, [inaudible] they identified that you can’t injure or change biomechanically one joint of the spine without starting to affect the others. Inevitably what ends up happening are these little hinge joints start become arthritics and they start to enlarge too. Now your core muscles continue to get weaker. There’s that imbalance. The lower extremities are still doing pretty good to maintain you, you still have repeated injury to your first and second line of defense to the spine. Now there’s a different type of flexibility issue. Because now you’re less and less and less active. And when you are less and less and less active, what are you doing? You sit. Right? You sit a heck of a lot more. I know. I need to sit down every time I go see a patient. I take a seat as soon as I walk in a door. The idea is that unfortunately something happens with the flexibility when you sit for too long. Also when you lie on your side when you’re sleeping kind of fetal position but inevitably when you sit, the muscle that actually helps you flex that leg of yours, called the hip flexor, gets tight.

Now you not only have that tightness in your hamstrings but now you’re getting tightness of those hip flexors. So when you stand up you’re like… walking your hands all the way on up. Now what happens to the spine? As you are instead of bending forward putting pressure through the disks, cause you can’t stand up straight, those hips are laxed, you stand back and now you’re putting pressure more on those little hinge joints. What are those little hinge joints called? Facets. What’s the technical term? Zygapophysial joints. Alright. What ends up happening, those Z joints grow and grow and grow. They are not truly growing but they are laying down bone and calcium deposits and bone spurs. That disk starts to flatten out more and more and more. And the end result is, look that happens to that canal where those nerves live. That’s’ spinal stenosis. That’s’ the biggest issue that we’re worried about in the aging spine. Back pain, yeah. Muscles, ligaments, those Z joints create back pain. The thing I am concerned with is always the nerves. That’s’ what people go to surgery for. That’s’ what we’re trying to prevent. Bottom line is, what do we do? Well, if you don’t use it you lose it. The bottom line is that first stage first evaluation. The idea is that we need to figure out, biomechanically everybody is different, I’m giving you just kind of general guidelines what kind of gets tight over time, what kind of gets weak over time but everybody is an individual. We need to treat you as such and we need to come up with a specialized exercise program to cross train so that no matter what your functional activity is that you want to do, again, whether it’s washing the dishes or running the marathon, we need to train you appropriately to do that activity. It’s very sports specific. That’s what we understand as being the most common way for us to describe, it has to be what you like to do.  If your goal is to do this versus this, tow totally different patients, we need to come up with a reasonable goal to achieve these things. The idea is that having a good therapist is the most critical component. That’s’ why this video is not all end all. It’s called Physical Therapy Assistant for a reason, the assist of physical therapist, but nothing replaces having the therapist look at you and say “Did you have a knee injury?” “20 years ago I did. Why would that be an issue?” Well, again, if you don’t truly recover from an injury in your legs, it starts impacting your back. The bottom line is this, you know, I as a physician like you to put you in one of two categories when you come in to see me. You got back pain, again, what do we use? We use NSAID medications to reduce the inflammation of those arthritic joints of the muscles and the ligaments, sometimes we use muscle relaxants. Once we get things to calm down, we start [inaudible] rehab program. The soon as we can. If there are ridiculous symptoms meaning those nerves are involved in some way, were on a different page here.

We need to take a little time, we need to get things to calm down in order for you to have success in increasing your activity. What I mean by success in reducing the nerve irritation varies greatly patient by patient. Sometimes you come in with that sciatica, everybody knows, thinks, they know what sciatica is. But in general sciatic nerve is just the nerve and then the irritation of that nerve. But in actuality the idea is that a pinch of a nerve here or an irritation of the nerve here could be of variety of different factors. Is there mechanical pressure, is there just chemical inflammation, [inaudible] arthritic. In which case the idea is that we give you anti-inflammatory, a lot of times we start off with non-steroidals, but sometimes we have to use steroids or injections of steroids to get things to calm down. The key component that I love in my business is that narcotics don’t work for this. They just don’t help pain that is nerve related. It’s been shown. So I don’t give any narcotics. I don’t think the work very well. There’s a very good use for narcotics, for other things, post surgically, for musculoskeletal injuries that are a component of that but I find that using a number of different medications to reduce inflammation, getting the muscles to relax, in addition to non-narcotics can be the main way to decrease the irritability so that you can have better success integrating into an exercise program that is sports specific no matter if it is tennis or pickleball.

Q: How does osteoporosis affect the spine?

Very good question. First and foremost there is, I’m not saying you have this, there is a little bit of a misunderstanding or miscommunication because there’s a confusing thing. Osteoporosis versus osteoarthritis. They both sound very similar but they are very different. First and foremost these joints back in here are kind of like an osteoarthritic issue. Osteoporosis is a density issue with the bones themselves. It really doesn’t impact as far as what we’re talking about here biomechanically unless those bones start to fail. Which is kind of like a completely different talk and what that failure of the bone essentially means is it starts to fracture. But sometimes we need to let that body heal. When there’s fractures involved, all bets are off. Sometimes even narcotics do work for this. That’s my exception. The idea is that there are additional treatments that are used for osteoporotic fractures. We can inject cement into the bone and cause that bone to become solid. These are things Dr Wagner, our spine surgeon does but the idea is that there needs to be an understanding that there’s two different things here that are kind of similar in name but very different in their effects on the spine. Osteoporosis versus osteoarthritis.