Foot Detox Blog

The answer is no. Does physical therapy cause the tear to heal? The answer is no. But what they do is reduce the symptoms down to a tolerable level and by retraining the other muscles in the shoulder; most patients can go on with their lives. You have to remember that about 1 out of 3 individuals over the age of 70 has a rotator cuff tear and not everybody has pain. Because if you look at the population here in Bethlehem, if 1 out of 3 people over 70 had a painful rotator cuff, we’d have people lined up from here down to [inaudible] waiting for treatment of their shoulder. Even with a rotator cuff tear, surgery is usually the last resort. I myself have a small rotator cuff tear in my shoulder, bothers me once in a while. I take a little bit of anti-inflammatory, take it easy for a little bit, gets better, I go on about my daily activities. Let’s talk about the elbow. Basically the most common elbow problem in us more mature athletes are what are called epicondylitis. And that’s a fancy way of saying tendonitis which is a fancy way of saying irritation or inflammation of tendon. In medial epicondylitis, bump of the bone here on the elbow on the inner side, we call that golfer’s elbow. Quite honestly, in 25 years of practice, I think I’ve taken care of 2 patients with golfer’s elbow who actually played golf. Everybody else gets it from lifting weights, work related activities, whatever. Then there’s lateral epicondylitis, that’s the bump of the bone on the outer side of the elbow. That’s also a tendonitis. That’s usually called the tennis elbow. In 25 years of practice I think I’ve taken care of 3 tennis players who had tennis elbow. Everybody else gets it from a lot of computer work, or repetitive things like checkout ladies [inaudible] for 8 hours a day. Or patient comes in and says “I have a pain here.”

You determine they have tennis elbow. I’ll say “Any change in your activities?” “My husband and I were remodeling the house and it was my job to paint the trim and I did this for 8 hours a day.”  The treatments for either medial epicondylitis, golfer’s elbow, or lateral epicondylitis, tennis elbow, are the same. It’s medication. Things like Advil or Relieve. There’s now a really nice rub on version of anti-inflammatories called Voltaren Gel, I prescribe it probably by the 55 gallon drum. It’s really good because it doesn’t, although theoretically they have to use same warning labels, it does not get into the blood stream like the oral medicines do. And patients who are on Coumadin or Plavix, who are just not very healthy, I’m still very comfortable having them use that medication. So you can treat it with medication, you can treat it with physical therapy, you can treat it with a little band that goes around. We call that a counterforce brace. You can buy them over the counter or you can get a really good version here at Coordinated. Cortisone shot is sometimes temporary but often works very nicely. And last but not least, surgery. Some years ago I went to a conference on upper extremity problems and one of the lectures the title was “Is there anything new in tennis elbow’?” and the lecturer spent half an hour talking about tennis elbow and the conclusion was – no. The high shock wave stuff and plasmapheresis are not really proven to work for tennis elbow. The point of his lecture was that if you take a 100 patients with tennis elbow, and you treat them with medication, or injection, or therapy, or surgery, and you look at that same group of patients a year later, the same percentage have gotten better no matter what you had done.  The point is – don’t rush into surgery. I’ll talk briefly about the knee. Dr Rudolph covered that really nicely in depth. I’ll talk about the meniscus a little bit. You have to be careful in the older athlete because usually a torn meniscus or what we call meniscal pathology, coexists with arthritis. If the patient has mechanical symptoms like Dr Rudolph said, the locking or the catching, that might tend to [inaudible] surgically. The problem is that arthroscopy for the meniscal disease in the older athlete, 50, 60, 70, who also has arthritis; the success rate is only about 60%.

Success being defined as [inaudible] reduction in pain and getting back to your regular activities. I usually drag my feet about getting patient into surgery who has a meniscal tear and the arthritis. There’s other options to treat the arthritis. What are patellofemoral problems? The patellofemoral joint is in front of the knee, it’s between the knee cap and the thigh bone. Usually patients have pain in front of the knee. Their pain is worse going up and down stairs or getting u from a seated position. And even in the more mature population, the majority of patients who have patellofemoral pain are women. Why is that? I don’t need to tell you women are built a little differently than men, tend to be a little bit wider at the pelvis so you all tend to be knock-kneed, your knee cap instead of riding down the road straight wants to drive this way. 95% or more patients with front knee pain, patellofemoral pain, will respond to nonsurgical treatment. That’s’ another…if I tell you you have patellofemoral pain, I’m going to be kicking and screaming before you can drag me into the OR and operate on it because it doesn’t usually help. Therapy, medication, a good knee brace and the right kind of exercise is not the squats. Let’s talk about total joint replacement and sports participation. Definitely the top list of activities, definitely a no-no. Why is that? Because they all involve quick starts and stops, they involve repetitive impact. In the case of football, I believe it was Dion Sanders, there was a pro football player who had a total hip replacement and tried to go back into playing football and that was like…Bo Jackson? I’m sorry. Thank you. That was probably the craziest thing I’ve ever heard. Basketball, football, gymnastics, handball, singles tennis, jogging, volleyball and high impact aerobics. Again why? Remember your total joint is a mechanical product and like all machines it can wear out. Now yes, walking, swimming doubles tennis, golf and low impact aerobics. Why? Because again these are not repetitive heavy duty impact activities. Maybe if you’ve done these activities before joint replacement and you are reasonably proficient at them, then you might be able to go back to those activities after your joint replacement. That would be things like weight lifting, downhill skiing and skating. Now I’m a skier, if you can go back to downhill skiing, that means no moguls, you keep both skis on the ground. You know, don’t be crazy. This is Jerry Rice who at the age of I believe 42 played in his last professional football game. No it’s not 75 like a golfer but I can’t imagine at the age of 40 or 42 running down the football field with 10 guys who basically wanted to kill me. I have to say I think jerry Rice is my hero. Thank you.

J. E. Kooch:

I did my undergraduate degree at West Virginia University in exercise physiology. Then I went off to stormy Buffalo and I did 2 years of graduate school in biomechanics. Then I went out to cold, snowy Chicago and that’s where I did medical school. I’m an osteopath and then I went to Northwestern for my residency. That’s where I became what is called a physiatrist. Does anybody know what a physiatrist is? Anybody? What is it? It’s a rehab specialist, yes, but specifically the doctor of what is called physical medicine rehabilitation. We initially got training in things like stroke, spinal cord injury and brain injury and it’s really to deal with how to function on a day to day basis based on that impairment that you have. We also got a lot of expertise in musculoskeletal medicine. That’s kind of my area of expertise, obviously specializing in spine. The idea is that throughout my education a lot this is based on functioning and that kind of is the theme of this talk. It’s that functioning can be a lot of different things to a lot of different people. Your goals and aspirations are based on your functioning whether it is your activities of daily living, to try and make sure that you can wash the dishes or play Batman. Whatever that function is, that’s what we’re trying to restore. The exercise is the element that I’ve always used to try and be a means to the end. The idea is that, I’ll just start writing things down here. There are 5 lessons we’re going to go over. First lesson is anatomy. Let’s hand out some of these models here. I want you to kind of pass them around a little bit. This is the big one I’m just kind of show you briefly essentially what we’re looking at [inaudible] segments that I’ll pass out. The spine itself is a collection of bones that’s stacked on each other and these are the little bones’ segments. We are going to be talking primarily about the lower back cause it’s the most common area that we injure. The idea is that there are actually 3 joints in between every bone of your lower back or [inaudible]. The idea is that if you take things in cross sectional view and you start looking at them like this, you’re going to see a disk, it kind of looks like this, as being joint number one. It’s the most popular joint. Everybody’s like when you went to see Dr Kooch “How are your disks?” There’s more than just the disks but it’s a very important component. As we look here, this is the bone itself but the disk itself is in between that bone and that’s here. They key thing to that is you want to think of kind of like the jelly donut although it’s shaped kind of like the kidney bean. The jelly on inside helps out with compression. There’s two other joints that are pretty darn important also in the back part of the spine. These are little bones that you feel right on the middle line of your back. Right next to that on either side are two little hinge joints. They are called zygapophysial joints. I’ll quiz you later on that. But what we really do is we call them facets. And they are little hinge joints. They operate kind of like your knuckles.

There’s one on either side. This is a rudimentary drawing of your spine but the concept is that there are 3 joint here and they kind of form a triangle. The key component that is different in the spine than it is in any other quote unquote joint in your body is that it has another function that’s equally if not more important than any other joint in your body. And the fact that it houses and protects a very important nerve structure. It runs through this canal here. The spinal cord starts in your brain, runs down through the center of this canal and interestingly enough it ends just at or slightly above your belly button. Most people don’t realize that. The idea’s that from that point down is a series of nerves running through this canal here and these are the ones that exit the spine and head down south through your legs. Remember this model. That’s schematic. Our next question. Who can name lesson number two? Physics! Very good. This is tough, I know. The idea is physics is very important now to understand because we move. What happens to the spine when you move?  The idea is that we are a product of what we do and how we do things. And that’s essentially what is called biomechanics. No matter what area that I was studying in, everything kept going back to this thing called biomechanics. That’s really what we do and how we do things. The idea is that you can get very involved and I’ll talk briefly about what happens in spine, but there’s other areas of biomechanics that are equally important. The idea is that if this your spine as you are facing this direction, one of the key things to understand is that when you bend forward you are loading that front joint being at disk. You’re going to be putting more pressure, I’m exaggerating, but the idea is you’ll be putting more pressure towards the front where that disk lives. Increasing the pressure at that disk. When you extend back, you’re going to be loading those facet joints.

The idea is that that’s really important because when we talk about injuries to the spine and how the spine degenerates, again, it’s all about forces, so we go back in history where we find out what was happening at the time of the injury or what biomechanically happens and changes throughout life that can impact that spine. The other component though is all the things these guys are talking about. The additional injuries that occur, in particular when we’re talking about lower back with all the injuries and degenerative changes that we start having in our legs and feet and in our arms when we’re talking about neck. Case in point, the idea is that if you bring it down to the forces or when we’re talking physics, every time you put your foot on the ground, it generates ground reactive forces, it’s what they’re called. But in general it’s forces that come up through the foot, they come up through your calf, thigh and then go up to your spine. If everything is working great you’ve got great dampening forces .You decrease forces. As soon as your foot hits the ground your foot beautifully dampens those forces, your knee dampens those forces, your hips dampen the forces and then the forces that go through the spine inevitably are much less. The key component is, you start injuring these areas.

Very rarely can you repair the meniscus. If you put stitches into something that doesn’t have blood supply, it doesn’t heal. So it just tears again. So usually this is treated with a [inaudible]. Achilles rupture. Talked about this earlier. It’s very common in 20-40 year old athlete. Fancy way of saying it, eccentric force on a stressed tendon. Basically that Achilles tendon is taut, maybe just landed and if you go just a little bit too far, tendon can tear.  Usually it tears in that same [inaudible] where I mentioned there’s not a great blood supply. It’s the weaker part of your Achilles. Landing awkwardly after jumping, suddenly turning position or of course if you’re trying to run a first base while making the last out in the World Series. For you Phillie fans out there. And there it is. Last out of the World Series for you Phillie fans. That’s an Achilles rupture.

Symptoms: snapping, tearing sensation. Almost feels, people tell me they felt like they got shot in the calf. Significant weakness, can’t get up and walk. Inability to push off. Have to have your teammates carry you off the field while the other team is celebrating. Treatment. It is usually treated surgically. On occasion I treat these nonoperatively, somebody will be in a cast for 6-10 weeks but in general by far and large most orthopedic surgeons will treat this surgically with an incision, stitching the tendon together and getting going with physical therapy early. I think this is my last topic. It is a chronic ankle sprain. We all know what ankle sprain is but what I’ve seen in former and present athletes are repetitive sprains where you may have had just one really bad sprain that never healed or your ankle just keeps spraining. Eventually what happens is the ligaments on the outside of the ankle stretch out to the point where they just won’t snap back to where they belong. Most of the time after a bad sprain, 85% of the time, even with the worst sprain, those tendons will scar down to where they belong. But if ligaments become too stretched out you have a symptom of a chronic ankle sprain which means as you’re walking down the street you just hit a pebble and boom – your ankle turns and it can happen repetitively over and over. There’s a nice ankle sprain. A volleyball player. Symptoms: pain in the outside of your ankle, instability, feeling like the ankle is going to give out, can’t participate in the cutting activity, unable to walk on uneven surfaces [inaudible], notice every time you’re walking on  [inaudible] road the ankle rolls. This examination… anterior drawer sign is something that if you’ve ever had your ankle examined…basically I kind of stabilize your leg bone and pull on your heel bone and if there’s too much play there that means to me that ligament is chronically stretched out. X rays and MRI scans can help. Treatment. Nonoperative treatment for chronic ankle sprains doesn’t really help much. Those ligaments are so stretched out that even with all the therapy in the world, a kind of Arnold Schwarzenegger strength ankles, and that ligament is still too stretched out so it just buckles. Some folks they just don’t want to talk surgery. They don’t even want to think about it, you can put them in a brace that replaces the ligament but you’re in a brace all the time. Surgery is usually a two part procedure. First again through the arthroscope which is one of the really important tools. Look inside your ankle joint, clean out any scar tissue or any junk that’s built up and then go to step two which is tightening up the ligaments. Usually this is done by tightening up your own ligaments. Very rarely are those ligaments so stretched out that I can’t find them and bunch them together again. If that doesn’t work sometimes you have to get into a more complicated surgery where you try to create new ligaments from a host or different sources. That’s the end of my talk on the aging athlete. Hopefully nobody feels like this guy right now. We’ll have the questions after everybody else has talked. Thank you.

John Williams:

Aging has effects on all of the parts of musculoskeletal system. Muscle, the mass of the muscle and the strength of the muscle decrease with aging. If any of you have watched that commercial, I believe it’s for an insurer, they quote a number of 8% every 10 years over the age of 40. We are all headed in the wrong direction if you look at that. The effects of aging on muscle can be reduced by exercising. Now, effects of aging on bone. Bone density decreases after the age 35, particularly in women. In men it only decreases by half a percent per year. In women it’s 1.5% and after menopause it’s 3% per year. If we had time I could give you a separate lecture on osteoporosis but we’ll hold off of that. Bone loss can be reduced by weight bearing exercise and proper nutrition. What’s weight bearing exercise? Weight bearing exercise can be as simple as walking. It does not have to be running. Proper nutrition – calcium and vitamin D. How much calcium and how much vitamin D? Is there anybody in this room that really likes to drink a lot of milk? You’re going to see a few hands but in general, I used to say to patients “Only people on dairy farms drink a lot of milk” So I had a patient say to me “I run a dairy farm and I hate milk.” How much calcium and vitamin D you need to get? You need to get about 1500 mg of calcium and you need to get about 800 units of vitamin D. that’s a lot so we should all be on calcium supplements. Effect of aging on cartilage. Remember doctor Rudolph told you about cartilage. Cartilage is the covering end of the bone that makes up the joint. Basically it is a decreased elasticity. Wight bearing exercise is ok but not high impact aerobics or really high impact running. I’m not saying don’t run. I’m just saying in moderation. Ligaments. Remember the ligaments are the things that hold the bones together. It’s the thing that keeps your knee going this way instead of side to side or falling off. Like muscles, like cartilage, the ligaments can lose elasticity with aging. How can you get around that? Well, good stretching before activity. What’s good stretching? Good stretching is gradual stretch not what’s called a ballistic or bounce stretch. You do bounce stretch and you get to see Dr. Rudolph and me. Let’s talk about exercise. Particularly in our age group, the preparticipation evaluation is important. It’s a good idea not to have done high school athletics and then at the age of 50 or 60 or 70 say you know I really have to start exercising. Most of us at this age have medical issues whether it’s blood pressure or heart problems or diabetes and you should see your internist or family doctor to make sure that they say “Look, your heart is healthy enough to exercise.” Orthopedic issues. You know, we get less flexible as we get older. If you already have preexisting knee problems or ankle problems or shoulder problems, then there’s going to be certain exercise types that you should modify or stay away from. That’s why it’s important to, if you have an orthopedic or musculoskeletal problem, to talk to your orthopedic surgeon or your physiatrist about what kind of exercises can I do. Acute injuries. We older athletes have a lower incidence of what we call acute traumatic injuries. Which means “I fell down and broke it” or whatever. I think that is due to the wisdom of experience. Acute musculotendonous strains. Remember from Dr Rudolph’s picture, the tendon is the thing that connects the muscle to the bone. He talked about Achilles tendonitis. I agree with him, usually it’s surgical repair. Quad/patellar tendon tears.

Those tend happen more often as we pass the 35 marker, 35 years, and then get into 40s. A lot of tennis players, older tennis players, get it and that almost always needs to be fixed. If we want to talk about the upper extremity, you can rupture your biceps tendon and you can rupture it in two places, either at shoulder or the elbow. Most of the time if the biceps tendon ruptures at the shoulder you get a thing that looks like a Popeye muscle. I usually recommend patients that they do not get that repaired. Because surgery doesn’t really help to resolve all that much. It makes it look a little nicer but what you do is trade a scar for a Popeye muscle. And the few times that I’ve repaired acute traumatic injury, I’ve kind of been sorry cause the patient just, they want to be perfect, you know, “I was perfect before, why am I not perfect now?” Doesn’t work that way. Ruptures of the distal biceps tendon, that is the one at the elbow, unless you are very, very sedentary or you have medical issues, most of the time we recommend repairing those. Certainly, looking around the room here, looking at myself, I would say we are active enough where you really need that distal biceps tendon. And what does that tendon do? It helps you bend the arm, which is important. It also helps you turn the arm this way which is important if you like to do home repairs or if you play tennis. So most of the time we recommend fixing that. Chronic overuse injuries. That’s the most common injury in our age group. Cause remember now we’re smart enough not to get acute injuries and do really dumb things that maybe our children or grandchildren are doing but we maybe tend to do a little more than we should be doing and therefore most of the aging athlete injuries are of chronic overuse variety. Let’s talk a little more about the rotator cuff. Rotator cuff is a group of muscles inside your shoulder. I tell patients that it functions like a hinge on the door and that the big muscles are like a motor that opens the door, if we’re talking about that kind of door. One can get irritation or inflammation of the rotator cuff. How we get that? Doing too much of anything. We decided we were going to paint our ceiling, hanging wallpaper, trimming the hedges, playing tennis if we haven’t played in a long time.

That’s an overuse injury. Rotator cuff tendonitis almost always responds to what we call conservative care meaning nonsurgical care. Conservative care can include medication, it can include cortisone injection, almost always, at least in my patients, includes physical therapy. And what I tell my patients is once you’re done with the hard part of this, once you’re done with therapy, remember to do the exercises. Because what happens is, patients will get therapy, they’ll feel better, they’ll go home, they’ll say Dr Williams was really smart and then they come back 6 months later and then say “Wait a minute. My pain came back. Why?” And the first thing I say is “Are you doing your exercises?” And usually I get the sheepish look [inaudible]. Remember to do your exercises. There is a condition called impingement which is sort of associated with rotator cuff tendonitis. Impingement is when the space in rotator cuff is not quite exactly what it needs to be. And how do we treat impingement? I refer you back to rotator cuff tendonitis. We can treat it with cortisone shot, we can treat it with therapy, we can treat it with medication. If it doesn’t respond to treatment in, to quote Dr Rudolph, from lower extreme to the upper, in 12 months, then usually think about surgery. It can be done arthroscopically or open. Rotator cuff tears. There’s little tears and there’s massive tears and there’s tears in between. Usually we base our treatment of rotator cuff tears on the symptoms and their response to conservative nonsurgical treatment. Again, rotator cuff tear, just like tendonitis, you can treat it with cortisone shot, with therapy. Does the cortisone shot cause the tear to heal?

This is a cartoon from the back. Calf muscle, big band… your second muscle is back here… then it becomes a tendon right down here. There’s two muscles in your calf, gastrocnemius muscle and the soleus muscle, which then come down to form this Achilles tendon and inserts down into the heel bone.  Treatment once again, nonoperative: stretching, bracing, casting. In this case we never…I never like to have cortisone injections. Although cortisone is helpful in a lot of places in orthopedics, getting injections around the Achilles tendon always worries me. Higher risk for rupturing the tendon. There’s better ways to treat tendonitis in this area than getting shots there. Some people may have heard about these newer treatments. PRP, it’s all over the news, everybody’s heard about it ever since the Steelers won the Superbowl three years ago. Basically this is a concept where you have some blood taken, they spin it down to get down to the plasma and then inject that plasma into a body part. There’s not any great science now that it works. You’ll hear plenty of people say “Hey, I did it. Works great.” Science isn’t quite there yet but it’s certainly something that’s on horizon, we’re testing it to find if it is really something to consider. Shockwave, this ultrasound shockwave treatment, again, it’s a newer concept. It’s been shown to work sometimes with tendons of the elbow, maybe in the heel. Again, one of those things we are certainly looking into. Surgery for the Achilles tendon. Same rule always applies. It is only performed when there is a failure with conservative management. I’m going to briefly talk about this because this came [inaudible] day-long conference on tendonitis surgery but essentially  if you’re having he insertional Achilles pain which is directly where the tendon is inserting on to the heel bone, sometimes there’s a big spur or calcium build up down there. In order to get that out you got to peel the tendon off the bone, remove that spur and reattach the Achilles to the bone again. If, however, you gotten this tendonosis I mentioned earlier where this pain is directly in the Achilles and you can see this on MRIs and things, it’s a different sort of surgery we don’t want to go down to where it inserts itself onto the heel, in this case you have to actually excise or remove that thickened, scarred down piece of tendon and in order to strengthen it we do different kinds procedures such as tendon transfers. This is a little more involved surgery.

Plantar fasciitis. The most common problem you see if you see foot and ankle injuries in the office at all. Everybody calls this heel pain, or bone spurs or heel spurs but in general 99% of the time when somebody comes to the office with heel pain, it’s plantar fasciitis. I’m going to show you a picture again, another cartoon what this Plantar Fasciitis is but think of it as this thickened band of tissue that radiates from your heel all the way up toward your toes. The pain is not caused from the bone spur and nobody wants to believe me but that’s true. The pain is actually caused from the band of tissue that has these microscopic tears in it. You might have a spur, you might not have a spur, it doesn’t mean you don’t have Plantar Fasciitis. Plantar fascia does help to maintain the arch, if not the only thing that gives you an arch. Symptoms are classic. Pain when you first wake up in the morning or after prolonged sitting or after activities. You’re up, you’re running, you’re doing fine until you sit down for a coffee break or go to sleep at night then this plantar fascia crinkles up on itself, you go to stand up, you re-tear it, it hurts like crazy until it stretches out. That’s usually the typical presentation. So here’s a picture of this band. I can’t call it a tendon or a ligament; it’s really just a fascia or a band of tissue that runs along the bottom of your foot. There’s your heel bone, here’s this fascia, goes all the way up your toes and right there. I guarantee there’s people in this room that have this or have had it or knows people that have had it, that’s where it hurts you. It’s right there on the inside bottom of your heel, worst when you first get up in the morning.  Causes. There’s a million causes of Plantar Fasciitis. Sometimes we can say it’s from an overuse injury, sometimes it’s weight gain, sometimes it’s a new activity. The fact is most of the time we don’t even know what brought it on or what the causes were. Treatment. Almost always nonsurgical.  And I wrote it in big capital letters three times: stretch, stretch, stretch. How you stretch, doesn’t matter. If you stretch with a therapist, if you stretch at home, if you stretch with a fancy [inaudible], whatever you do stretching is the key. There’s other things that people will talk about. However you do it, stretching is the way to cure this problem. Orthotics, fancy way to stretch your foot while you’re in your shoes throughout the day. Night splints or just ways to stretch it throughout the night time. I do mention cortisone injections here.

I rarely would use a cortisone shot. If somebody comes in and they are just in a lot of pain and can’t even stand on it then the cortisone might help to decrease the inflammation and make it feel better but it’s not going to cure your problem and it hurts like crazy too so I don’t do a lot of those shots. Surgery is only indicated if you’ve had 6 to 12 months of failure of conservative management and that’s because this almost always goes away with the right stretching exercises. If you do operate it can be done either through an incision or through a scope again but basically we’re doing the ultimate stretch, you’re just releasing that band of tissue. Stress fractures. I’ve talked about this briefly earlier. I’m not going to go into it too much. It’s just an overuse injury to a bone. “Paperclip concept” that I’ve talked about earlier. It can occur in any bone in the leg. Fairly commonly seen in tibias, which is your leg bone. You might think that you just have shin splints and it’s going to go away but in fact it could be a stress fracture. In heel bone, calcaneus, that’s a big runner injury or somebody does a marathon and they just can’t stand on their heel the next day. Metatarsals, these are the probably the most common place for stress fractures in the foot. They are the bones that connect your back of your foot to your toes. Diagnosis. X-Rays are usually normal. You take a paperclip and you bend it a thousand times you get little cracks in there that don’t show up on an X ray. Next step is either an MRI scan or a bone scan and that’s the way we usually will diagnose this. Treatment. Easy – eliminate the stress. Stop the activity, so it’s either a cast, a walking boot or some sort of brace to take the stress off the area. If you’re having trouble getting these things to heal there are more aggressive treatments such as these bone stimulators and injections and extremely rare for a stress fracture not to heal. [inaudible] or it’s been there for months and months and months sometimes surgery, just like we treat any fracture, with plates and screws and whatever you need to fix the fracture. Last problem I’m going to talk about in this wearing down is arthritis of the big toe. Arthritis as most people know is losing the cartilage; you lose the Teflon coating against the bones. A very common place to get the arthritis in lower extremities is in the big toe. It’s not your toe, it’s where your toe is connecting to your foot. It’s called the metatarsal phalangeal joint. Extremely common place to have this. Very common in former athletes or runners. It’s an old turf toe injury or old runner injury. Your first MTPJ which stands for metatarsal phalangeal join, we’re going to call that big toe joint, takes on a lot of stress and it’s an area that is very common 20, 30, 40 years after the sport that that area gets arthritis. I just mentioned this wearing down of cartilage in the area.  Sometimes it’s a single injury. A lot of [inaudible] or up on their toes. Somebody can fall on the back of their heel, jam that big toe up and it hurts for that game or for that week and goes away until 20 years later. [inaudible] I can talk to that one on an experience. Symptoms: pain in the area, swelling, bony deformity, loss of motion. All these things go along with arthritis. Diagnosing this, usually X rays. [inaudible] across the room. Nonoperative treatment for arthritis in this area: changing your shoes, try orthotics, maybe cortisone injections and medications we’ve talked about. Operative treatment very common for somebody who has such bad arthritis that doesn’t go away on its own. Arthritis never goes away, it’s the symptoms we are trying to treat. If it’s mild, only a few bone spurs in the area, maybe you can do a simple surgery like “clean up surgery” where you remove the bone spur, get the toe moving a little bit. More often arthritis has gotten much more severe and in this joint particularly joint replacement, like people who’ve had the hip and knee replacement, simply don’t work.

There is just too much stress in this big toe joint. I’m a proponent in this area of joint orthotesis which is a fancy way of saying to fuse the bones together. If you fuse them together in the right position they don’t hurt, they don’t move and you can still get into all, just about any activity you did beforehand. Now we’re into acute injuries. This is no longer the chronic wear and tear. These are some things that a lot of people have seen, had or know about. Torn meniscus doesn’t have to be in an athlete of 20. This can be in 40, 50, 60 year old folks. 70 and 80 year olds. Meniscus is the shock absorber part in joint of knee. It’s between the femur and the tibia. You have two of them, one of them inside one in the outside. They are these two C shaped bands of tissue that are very important for protecting your knee but unfortunately don’t have a great blood supply so once it’s torn, most of the time it stays torn. Twisting injuries to the knee, hyperextension injuries to the knee. And once you’ve gotten a little bit older that cartilage is not as rubbery as it used to be, it gets little more stiff so sometimes it’s not even one injury it’s more of a repetitive wear and tear thing. You can get cartilage wear and tear as well. Symptoms: knee swells, catches, locks, sometimes feeling of instability or your knee giving out, loss of motion to the point where some people [inaudible] they can’t move it at all. Diagnosing this is usually by examining the patient and of course MRI scan is critical in diagnosing meniscus tear. Yeah, I saw that injury. That guy might have a little bit of a meniscus tear potentially. Treatment. Unlike overuse injuries this problem is usually a surgical problem. You can try nonoperative management therapy, injections,  [inaudible] Once it’s torn most of the time it doesn’t heal itself. Usually this is a surgery problem done nowadays through an arthroscope which is a camera, they put a camera into your knee, usually one other incision with their little tools and then go in and remove the torn section of cartilage.

see the video: http://vimeo.com/61096362

Jason Rudolph:
The aging athlete. Here we all are. Everybody wants to be able to run wind sprints after your 80s and along with wind sprints after 80s come injuries. This is one of my favorite pictures. This is my ultimate aging athlete. Nolan Ryan, if anybody remembers this 20 years ago or so. He was 46 or so and this young buck named Robin Ventura decided to charge the mound and he clocked him, knocked him unconscious and that was the end of that. The aging athlete, I think, can still be a… yeah…pretty aggressive athlete. Quickly about me. I’m an orthopedic surgeon who specializes in foot and ankle trauma and all sports medicine type injuries. I’ve been in the area for the past 12 years. Board certified in orthopedic surgery. I do live locally and I try to treat all my patients like I would treat my friends and neighbors. I did play football like Gary mentioned. I have either suffered, am suffering and certainly will be suffering the repercussions of that so I kind of know exactly what a lot of the injuries are like and how to recover and what it’s like to be injured. A quick outline. We’re going to try to move through things relatively quickly and [inaudible] time in the end to ask any questions. I broke it down into two kinds of injuries. You got the overuse injuries and the acute injuries. Acute means something that literally just happened; overuse is more of a wear and tear chronic problem. Definition of an overuse injury: inflammation of a body part due to too much stress on either a normal area or normal stress on an abnormal area. I try to describe that like almost like a repetitive type of injury in certain spots. If you have a normal Achilles tendon but you just over do it, that tendon could become injured. Then again, you can have abnormal area like maybe you have a little thin bone or osteoporotic bone, you have normal activities creating injury to that abnormal area. Repetitive activities to a specific body part can include lots of things. Deciding you’re going to install a roof in one day, doing the entire P90X video, or one of these crazy videos, the first day. I got it in the mail for Christmas, I’m going to do the whole thing today. Or deciding to take up jogging cause you jogged 30 years ago so you go for a nice and easy 10 mile run. [inaudible] Tendonitis. This is all sort of definition stuff so that we can move through some of these problems later. Tendons are the piece of anatomic material, let’s say, that connects a muscle to a bone. One tendon everybody knows is your Achilles. That connects your calf muscles to your heel bone. Bursitis. Another one of these overuse things we’re going to hear on. So what’s a bursa? Bursae are these fluid filled sacks that occur somewhere between, usually between the skin and the underlying bone. The concept is, you have these to decrease friction. We all have them under out elbows. When you’re resting on your elbows, your elbow moves normally. You have them on the sides of your hips. When you lay on your side the skin doesn’t rub into a bone. These are normal things we have but there are areas where we can get overuse injuries. A stress fracture. Again, this is what I was just describing as an overuse injury specifically to the bone. I see a lot of these. [inaudible]. It’s an increased stress [inaudible]. Classic there is the army recruit, joins the army and does too much walking that first day and he gets a stress fracture. The other one is normal activity but abnormal bone, such as osteoporosis. That’s described as a “paperclip concept”. If you take a paperclip and you bend it, you bend it, you bend it, it starts getting hot, keep at it and you get little cracks in it and that’s kind of what a stress fracture is.

The first topic is trochanteric bursitis. A very common problem we see a lot of time here. Greater Trochanter is this big, hard bone you can feel inside of your hip. Some people call that a hip bone. It is but that really is a femur. And that spot is called your Greater Trochanter. It has attached a lot of the muscles; the muscles that help you stand up straight, the muscles that stop you from waddling or waddling as you’re walking. Symptom of Trochanteric Bursitis is pain directly on that big bump on the side of your hip. Sometimes the pain will radiate all the way down the outside of your knee, sometimes it’s worse at night, sometimes it’s worse when going up and down stairs. Risk factors for developing this problem: repetitive activity, like you’re going to see for all of these overuse injuries the first thing I’d say is repetitive activity. Biking, stair climbing, running. You’re also going to get this from direct trauma right to the side of the hip where that bursa fills with fluid. This is a picture, a cartoon of your hip. These are the muscles I was describing that are coming down, another band of muscles that are going this way and that red hotspot right there is where this bursa is located. This other side is the same picture without the muscles attached, and this bump is the Greater Trochanter that we’re talking about. How do you treat this? Again, most of these things, these overuse injuries, are treated nonsurgically. Simplest thing – modify the activities. If you hit yourself in the tight with the sledgehammer, stop hitting yourself with a sledgehammer. Second thing we try, NSAIDs, fancy name, basically what we’re talking about is ibuprofen or Naprosyn, the anti-inflammatory kind of medications. Cortisone injections work really well. Its’ a quick way to put the anti-inflammatory rate where you want it to be. Although it is a shot, we’re taking that shot and putting it right where we want it to be rather than taking a pill where the medicine goes throughout whole body. Physical therapy. Sometimes this helps, sometimes it doesn’t. Most of the time we go to therapy when the simpler things like [inaudible] are not working. Surgery is extremely rare for this problem. Has been described that people who just simply don’t get better within 6 months to a year of conservative management in which case what we do is go and remove the bursa. We are talking either an incision or sometimes now we can go through tiny little holes and use a camera and slip an orthoscopic type of surgery. Next problem – Patella Tendonitis. Again we are talking about the tendon. This particular tendon is the one that connects the kneecap to your leg. Your knee cap or your patella bone to the tibia bone. It is very important in the activities that require running, jumping, kicking sports. Symptoms are pain directly along the length of the tendon. The pain may be intermittent, meaning it’s not there all the time but as it gets worse it can progress to being present throughout the day. Another cartoon of the patellar tendon. This is a thigh bone. This white band is your quadriceps tendons, your quadriceps; your big thigh muscles are on top. They connect to this patella or your knee cap. And all that force goes right down through this big, patellar tendon. There’s all these big, huge thigh muscles you have really go right through this one little band of tissue and that’s what help you or your tibia or your leg bone move. Causes again, like I’ve said, it’s a very common overuse injury. Repetitive stress to the patella. Same concept we’re talking about when we’re doing more and more activities to one spot and cause this inflammation. In Patella Tendonitis, since this is not a bursa, this is a real tendon, the cause is multiple, tiny small tears that occur in that tendon. Those small tears hurt. Normally when your body has these tiny, small tears in tendon, you can naturally heal them on your own unless of course you keep doing it repetitively over and over again where your body can’t catch up. Then tears either don’t heal or progress to a point where they can’t heal cause the tears are too big. Risk factors for Patella Tendonitis, the same thing. High intensity or high frequency of specific activities. If you suddenly increase activity, I see this a lot in runners where they have a half-marathon they are training for so this week I’m going to build from 1 mile to 10 miles. Again, same problem is these overuse injuries. Overweight, again, the simple concept that if you’re putting more force across a tendon, you’re going to increase the likelihood that that tendon is going to hurt. Tight quadriceps muscles or muscle imbalance, these kind of go together. When we find you’re into weight training and you’re overdoing one side of the leg, let’s say doing a lot of hamstring work and ignoring your quadriceps. Then all of a sudden your hamstrings are going to get stronger while quadriceps might tighten up. That tightening up can cause more stress across the patellar tendon. This comes into play when we talk about how to treat patella tendonitis. Treatment, same thing I’m going to say this over and over and over. Rest. Doesn’t mean there’s no physical activity. Doesn’t mean you runners have to completely give up on activities. Just give up the high stress activities. If you’re having pain from high intensity running, there’s elliptical, there’s bicycle, there’s swimming. There’s other ways to keep your cardiovascular up while the painful tendonitis heals on its own. Physical therapy comes into play a lot with patella tendonitis.

Again, the stretching we were just talking about, the strengthening of certain muscles, the adjusting of your body mechanics. This is something that physical therapists are very astute at and great at helping out. Because just because you think [inaudible] quadriceps strong by doing light extensions doesn’t mean there aren’t ten other exercises that are better to get that muscle stronger. I’ve mentioned in this, phonophoresis and iontophoresis, big fancy names for ways of getting steroids into inflamed area. Phonophoresis is where the therapist will use an ultrasound to kind of drive some steroid cream into the area that’s inflamed. Iontophoresis, same concept but they use electrical stimulation. These are all things that you might be treated with when it comes to physical therapy. Same thing. Surgery is very rarely indicated in patella tendonitis. Most of the time it gets better with simple things we’ve talked about in the nonoperative treatment. If the symptoms haven’t gotten better in 12 months usually that’s when you might talk surgery for this. Another tendonitis, Achilles Tendonitis. This is something that I see, like I’ve talked about, I see a lot of foot and ankle injuries in a lot of athletes. The Achilles tendon is the large tendon that connects the calf muscles to the heel bone. It’s the largest tendon in your legs. The blood supply to your tendon becomes important. I’ll show you a picture of this in a second. There’s great blood supply that comes from the muscles above. There’s great blood supply that comes from the heel bone below. But now you’re in this middle portion that really has kind of a lousy blood supply. That narrow portion is [inaudible] problem. That’s almost always where, if somebody ruptures the Achilles tendon that’s where it occurs, but also these overuse injuries, these tendonitis problems also occur in that area that has a poor blood supply. Symptoms, again, pain directly either along entire Achilles tendon, you can also have pain where the Achilles tendon inserts onto the heel bone which is a little bit different problem but we can see both of those. Usually the symptoms are worse directly after exercise. While you’re stretched out and running and using it, sometimes it doesn’t hurt as much until it starts to cramp up, get tight, become more inflamed. We’ll see that pain after exercise or many times in the morning. Risk factors are very similar. Once again repetitive injury, overuse activity. This is a big runner, basketball player, volleyball player, running and jogging sports. Again it causes the same microscopic tearing we’ve talked about. In the area that doesn’t have a good blood supply your body can’t get the stuff into that area to help it heal so that’s the area these microscopic tears may not heal. When things don’t heal the tendon becomes now a starved and thickened tendon that gets an even fancier name here, tendonosis we call it, which essentially is a chronic thickening of the tendon where now it’s at a point where your body simply can’t heal it and now it’s just a thick, scarred piece of tendon.

Many of us haven’t learn this and its interesting think that it goes a long way back, maybe even perhaps <inaudible> emotional eating because, i don’t know about you but and i think this happens to a lot of people when we were kids, if were upset you know getting bribe to eat a nice chocolate or a nice sweet <inaudible> something our parents <inaudible>. Our food has been associated with positivity on a basis like that in a way because, if we were good we would get treats and that type of thinks. So a lot of these emotional behaviors that we have actually had now, i think come from way back when, in a way. so it’s interesting, now just wait for Carolyn, she’s typing in something, yeah, she says, i was brought up to where you had to clean you plate whether you are full our not, yes and that is something, I think happens to a lot of us to and it is actually encourages negative behavior later on in life as we see that. interesting whit children, i don’t think we should be telling them to clean their plate because, you know, we can often over served them food as well and if their full they obviously wont continue eating very interesting stuff how stuff that occurs to us when were younger actually drive our behavior later on in life and were just really unconscious of the fact that were its come from, often we think that it might be a problem with us that were just have a lack of will power or we can’t get it together but these things do come  from a place so either that its driven by various hormonal factors , through past experiences and so getting to the bottom of it is no way easy but we can keep working on it and keep improving our health as long as we keep taking those small steps forward on a big believer in that one. So what’s next after this 7 day detox? i was hoping to have a few more people with us here today.

I know that  I had a few people e-mail so I’m going to post the webinar recording so they can  go and watch it later on but i was wondering if it may the day easier for you, knowing that other people had been in these process with you because i often find that its sometimes really difficult to do things on your own and having a bit of a community of people doing things together helps us to stay on track a little bit better even though they’re not with us in everyday life we have other people in the back of our minds and feel like were more supported and we feel like were more encouraged. So I’d be interested to know if that had any impact upon your application of what you are doing or you actually felt motivated to do stuff anyway.

I’m just waiting for veronica to write something in there so i can see she’s typing. Veronica just, it was great to have somewhere where i can ask questions also my hobby wasn’t doing the detox but wouldn’t buy things out so <inaudible> of the week. oh that s fantastic, now you’re welcome I’m glad you found this support helpful because i find it, it really does help for use to have community and be able to go and ask questions somewhere when we do help, when we do need that help and often we do need help, i mean it’s really hard to get by on our own and you know I’m always, I’ve stopped by my Facebook page and see if there’s any questions so you can always go and leave questions there for me and id be more than happy to answer them back. i did want to ask you if you wanted to continue on a path to a better you and share a little bit of what could be next with you if that’s ok with guys because, it actually wasn’t planned that i would do this and  i don’t want you to just think that I’m trying to sell you something because I’m not but i actually have a best you boot camp which i run online an I’ve got it starting in a few weeks so i thought that i would just tell you a little bit about what it’s about and  to see if you would like to join up and also if you might have some friends that  might be interested too because if you’ve really enjoy these webinars, this is something we do every single week and so i tell you  a little bit about it because even if you’re not interested, you might know somebody  who is and it’s good to just to know about it anyway.

So its called the best you boot camp, its run for 6 weeks in total and it’s not really your usual boot camp because when i think of a boot camp id normally think its somebody screaming at you, trying to make you go a million miles an hour, but it’s not like that, it’s all about creating the best you possible within the time frame. I’ve had a couple of groups go through the boot camp now  and they’re all have all significantly changed their life on many different levels and i think this is mostly because we do  this webinars every week so were providing real education that equips you with the tools and  strategies and techniques that you really need to be able to make this changes in your life long term strategy not just this is another diet and after this 6 weeks or after this 7 days it’s all over because i really try to teach people to  learn the true value  of you so that you can  implement changes long term because if you lose weight that great but maintaining it and keeping  it off that’s even better.  So in my program, there really is no counting calories, there’s no weighing, measuring or deprivation. we do follow a pretty similar template to the one that’s in the 7 day detox but it’s not quite strict and so therefore it’s not like fit total rules and regulations, its more around a healthy template and were always working off these healthy template because one thing that’s for sure is that a lot of weight loss programs or even health programs don’t take individuality into the equation and we all have different food habits, we all have different things that we like to eat and so when we have a healthy  template that doesn’t have strict set rules and regulations, we can focus on working out what works for us and that’s what i really try to focus on getting people to do <inaudible> boot camp program, i focus on getting people to really work out what works for them and i provide loads of sports to do it. so there’s tons and tons of support in my boot camp program, I’m a very hands on person as you can see, I’ve even also free webinars because i love to help people, i love to get involved with people and so we have lots of interaction, people have building, making friendships, we have people from all over the world involved and at various different age groups and so it’s a pretty good positive community where we focus on long term changes and breaking the dieting cycle.

So what the program involves and like i said this might be suited to you, it might not but maybe you can think of a friend or a family member, this would also make a really great gift to somebody i think. what the program involves is a whole 6 weeks of fun, fitness, food and <inaudible> and if you do like the format  of these webinars and i think they are fantastic, we have weekly live webinars just like this one and i found that there have been a very integral part to the success of my program because it keeps people involved with each other, it keeps us on track because we know we have this <inaudible> each week we’re learning about various different topics which all <inaudible> in just a moment some of the things that we go through and it also gives you an opportunity to ask any questions live as we go along to.

So this is really a lot of assurance and a lot of support and encouragement to back you, we have a very supportive community forum where you can go and  post your food diaries so a lot of people do that to get personal feedback from me of things that they might be able to change, ways that they can get more success, why they’re not getting so much energy, different things like that so we look at food diaries and in the program, you get 4 weeks of meal plans already on for you which is got a shopping guide and a preparation plan so you get <inaudible> whole recipe <inaudible> which has about 200 recipes, you’ve got access to home exercise plan so there’s a whole bunch of them in the membership site that have all the pictures and different work out so you can do, also have resources you can access and like i said, it’s really interactive and supportive as you can see from these webinars on variety interactive person and  i think that  it helps us get a lot more out of things because were not just in our own head and in our own day to day life. so some of the things that get covered together over the 6 weeks are, as i said, our live webinars and we have an overview to begin with so it’s just what’s involved and where to start and then we go over nutrition, fundamentals, so protein, carbs and fats and their roles in the body and what to eat and calories, portions and loading up your plate and then we talk about weight loss and health principles which is something, that’s ok Carolyn, see you, which is something that we talked about a little bit today but were going to that a little bit more and we talked about motivation and mind set and then we talked about all about sugar, so there’s a great webinar that discusses sugar, sugar and card addiction.

Yes i will for sure, thank you Carolyn, have a good day at work. Yes so, we talked about sugar and all sorts of things and we talked about the food labels and how to read food labels because i think a lot of people don’t know how to read food labels and the next scene we have a question answer session. So it’s a really good boot camp <inaudible> a lot of different stuff but it’s really helpful to people in moving forward and making progress so, ok then veronica, see you later. so for those of you who want to watch the replay, my boot camp officially starts off <inaudible> October 1st and if you want to join early <inaudible> because we’ll be having some extra webinars before the boot camp and there’s already some people who’ve joined up now and you get a head start on where you are now and support from each other form where you are now and you will be very surprised that  for just 6 weeks you get all these stuff plus if you join early you get some extra that the 6 weeks is just $47 <inaudible> well actually if you join up from today, it’s actually 9 weeks but I’d love it for you to join us in the best you boot camp because it is just a fantastic experience where you get loads of great support and staff from other people and a really motivated community. So yeah, like for just $47 it’s just really great value for especially whole 6 weeks where we get education, motivation everything else so those of you who are watching the webinar replay, you can.

I’ve posted a link just underneath the video here and you can go on  and have a look at all the things that are involve, all of the webinars that we have every week, what type of topics we will be covering like i said, you can have access to our community forum, where we all talk and engaged in and its just $47 for the whole 6 weeks, so you get super value with everything that’s involved in everybody who’s in it has been getting amazing results completely changing their lives on a really huge level. some people have started riding their bike, that one lady who started riding her bike for the first time in 11 years, I’ve got people who’s given up smoking, given up drinking, who totally transformed their lives and this is the power of community, this is the power of getting involved in something greater, it really does make a big impact but that’s not to say you have to get involved but obviously love it if you do join us, the more the merrier. so thanks of joining the webinar today or watching the replay, i hope that you learnt some interesting things about insulin and blood sugar and weight loss and keeping your health on track on a general everyday basis. so check out the best you boot camp were kicking of on October 1st officially and if you want that  extra support to gain a little bit more edge in your life even just to meet some new friends and have some fun then please come along and join us. So for now I’m singing off, have a great day.

It pushes excess sugar into our fat cells so anything that is consumed in excess will essentially cause fat gain. Most of us eat way too much food in general and general too much sugar. It’s kind of our innate, i guess, feeling in our innate drive to want to eat sugar. we have a natural desire for it because i think we know that it does produce so much energy and if we took ourselves back, sometimes i don’t like bringing in up cavemen kind of ideas but to the purpose of thinking about our roost and evolution and where we would’ve come from if we were  grazing in the wild, in nature then things <inaudible> would have been seen as massive source of the energy and we that innate knowing in us and so we just go for sweet foods and we all do, we love it because we know, but then now because we have excess so much sugar it really not such a good thing because the insulin which is our energy storage hormone is causing more fat gain <inaudible> see other serious health issues to.

So the simple equation is, we ate sugar it equals our blood sugar rapidly rises and generally speaking when we are talking about sugar, we’re talking about refined sugars, refined products. know that all sugar can raise blood sugar but some of it does act differently in the body because we have various different sugars to <inaudible> but it still all does break down to sugar no matter if its complex carbohydrates or a simple sugar just have a little bit different reactions in the body. so when we  eat sugar the pancreas responds, it releases insulin to normalize our blood sugar, the body works to hard and cells become resistant to insulin, that’s if we keep putting sugar in and inevitably the excess sugar gets stored as fat. so here we are, but all thinking fat’s the problem when still getting told not to eat saturated fat when in natural fat is sugar and interestingly enough, I was just doing some research the other day, i love doing research and I’m doing a masters in nutrition at the moment completing that and the government’s nutrition guidelines when they talk about reducing saturated fat, they’re actually referring to foods like cakes, pastas, biscuits, breads, pastries, lots of other things like that and  to me all of those foods don’t necessarily have saturated fat in them, they have refined carbohydrate, they have a polyunsaturated fats, unsaturated fats, like canola oils and vegetable oils in them and these are the types of foods they’re saying to avoid as far as saturated fat goes but somehow I think they’ve got it all mixed up.

So anyway, we won’t go into that now, but it’s an interesting argument. Just before we go on is there any other questions around that or got to pretty good understanding about insulin, no nothing coming in, ok. So basically when it comes to weight loss and optimum health there are just 3 simple principles, clean diet, this is number one. sometimes people get this mixed up and they’re doing 80% exercise, trying to go crazy every day, over doing it and still not losing weight and I wonder why, well it’s because number is clean diet, when we can get our nutrition on track that is going to equal 80%-90% of our results. it really is, people can lose weight without doing any exercise and activity, i have seen  numerous times, exercise and activity certainly does help, particularly in the situation we have just discussed with type 2 diabetes or getting the insulin resistance because we need to activate those cells but when we can clean up our diet and if we can maintain that this is  certainly going to produce the best result and what we’ve done in the 7 day detox is really cleaning things out and certainly probably not sustainable to that level on a long term basis because we want to include a few more flavors and want to include some flour to thickening sauces and that type of thing but this is  really a basic template and a really very good template that we’ve all known to over the past week on what to focus own.  so third in our equation for weight loss and optimum health is our mind set and this is a really big one that i don’t think a lot of people talk about very much at all and i don’t why because it is so important  in a very big part of the equation and that’s positive thinking and self-love and care because if we can’t maintain that positive thinking and if were not constantly trying to have that little bit of self-love and care then were not going to be maintaining that clean diet, were not point be putting ourselves as a priority and  knowing that this is really important for us, you know that we want to feel great  on an everyday basis.

I mean, i think we all know what it feels like to feel unhealthy, to feel bad, to put on weight, to beat ourselves up, we all know what that feels like and none of us really wants to feel like that on an everyday basis and so if we can change our mindset around, just thinking positively every day and focusing on self-love and care like  asking yourself if this really going to be looking after me or is it going to be a destructive thing and then we can really start to bring out actions and our behaviors in environment is what we really want and i think what most of us really want is just to happy and feel fantastic and yet often  our behaviors are contradicting really what our goals might be. so the basic template has been shown to us really in this detox that we’ve shared together and basically there’s a plate that were looking right now and  that might not look <inaudible> all the time certainly but we’ve got  bit of chicken breast, a half <inaudible> and a big salad or <inaudible> some good healthy fats and our vegetables and if we can stick to this basic template for the most part, then really that makes up a good basis, a good foundation for us where we have a bit of protein in every meal, we want to focus on our vegetables get loads of those in, a minimum of five serves a day wherever possible. this is a tough one because i find that most people don’t eat enough vegetables and were really need to be including a minimum of 5 serves a day so ongoing <inaudible> and i know that a lot of people have increased their intake through the <inaudible> detox so keep that up.

You can have carbohydrates from whole grains, gluten free ones in moderation along with things like the <inaudible> or the Keynewire or Emmermat, things like that that we can have those bits of carbohydrates but they shouldn’t be our main focus. i mean certainly that doesn’t mean don’t enjoy your bowl of brown rice pasta Bolognese occasionally that don’t use those carbohydrates as the main base of your food in every single meal try to get away from that focus and then include your small amount of good fats because we need fats for many different roles in our body. Now let’s just find that the simple question to ask ourselves is does it come from nature? Is it natural? because generally speaking, most of the stuff that we find on the supermarket shelf that were surrounded by today, its really not natural, most of it is made in the chemical laboratory and despite what the common message is that well it’s still a protein and a carb and fat <inaudible> nutrition panel and a fits within certain parameters, its fine. that’s actually what people think, that’s what researchers do think, that’s what a lot of nutritionist think, that’s what  a lot of academics think. personally i don’t believe that, i think quality is much more important, i don’t think things made in a chemical laboratory despite that fact that it may have something on the nutrition panel and necessarily very good for us and from what I’ve seen when, you know, examples of people who follow a detox like this or a diet that i recommend, we say the quality is always much more important. so generally speaking , in 80-020 rule, so if we had 21 meals a week, we might a get 4 meal lee way and 4 meals like eating what you want that’s a lot and i wouldn’t really necessarily recommend going to <inaudible> in those 4 meal lee ways by any means but it just means, you know, kind of go to a social event if you have it in, you don’t have to be too strict about it or <inaudible> deal on a weekend, sort of <inaudible> we don’t liv life in a bubble so we need to engage in social activities, we go out with friends, we might have dinners with them. having  a bit of lee way and our eating plan is a really good idea, i mean, if we can follow a 90-10 rule, i mean, i don’t like rules  as such but we need to have rules and regulations i think a little bit, otherwise we do tend to fall of the radar but knowing that we can have that lee way, i think, makes us feel less guilty about engaging in things like, you shared before veronica, going to your dad’s birthday and you were on a detox so it was great  that you’re only had 1 sip of champagne that i think that if we go to those occasions that is the time for us to let down the reigns a little bit. knowing that that’s perfectly fine and without beating ourselves up like we fallen off our diet or we  were really bad, no we weren’t, it was a special engagement, that’s the kind of things we do in social environment, the important thing is consistency and getting back to that ideal kind of eating plan that you follow on  an everyday basis, that is the most important think because whatever lifestyle we chose has to be sustainable we see things  in diets that cause deprivation where you feel like you can’t have what  you want.

It’s actually counterproductive and often causes a lot of <inaudible> and so we want to find something an ideal way with a basic template like these that finding in our ideal way that you can situate you’re eating plan and you daily habit around that you can sustain on a long term basis, so i hope that make sense. how  do you guys go with maintaining consistency, I’d be interested to hear about that, are you the type of person that’s able to maintain that or do you tend to binge and then come back and then yeah it’ll be interesting to hear that. I’m just waiting for those comments to come in because i can see people typing.

So veronica just shares that she usually maintains it except when working  or traveling and you know that’s the thing, we do when were outside of our normal routing in situations like that, we find it more difficult to maintain things because were not in our normal environment, were not in our routine so that’s fine, i mean, trying to not go too over board is definitely a main goal that perhaps you want to have a look at but generally speaking, we can accept that that happens and not beat ourselves up of it you know and i think that the important part is knowing that we don’t live life in a bubble we have to travel, we do things, we engage in things, thing that going to happen and actually contradictory, it’s not good for us to be  beating ourselves up and  getting <inaudible> we do get out of routine or whatever else. so yeah, thanks for sharing that. Carolyn says she can go for weeks or months eating well and then just get an attack of the binges, usually when have some sort of problem whether it be work or family which we all experience, i just have to try and control another why not with food, I’m a very emotional eater, you’re not alone by any means and thank for sharing that Carolyn because stress again is a big driver, stress drives out emotional eating a lot of the time and i think that it is one area that many people come undone including myself, were all, it happens to us all. some of that behaviors actually driven by our hormones because we naturally do crave the worst of foods when were under those circumstances and then often when we have stress as well, we lose our focus on ourselves and we might be easier so we find it more difficult to plan good food, we find it more difficult to get it together, different types of things like that, but i think we can definitely develop strategies of controlling that in another way other than food.

It’s a natural thing, we tend to reach for the sugar, that’s what we want to do, the energy forming foods because we’re looking for that energy and we get the energy again that we get to the end of the day, we get the crash, we feel that crap, we can’t sleep and we crave more sugar and this is what i call the blood sugar roller coaster ride and it really is no fun place to be. Carolyn says that she’s certainly has experienced the blood sugar roller coaster ride and she’s still fighting it now and then, getting better mainly just that time of the month and yes thank you for sharing that Carolyn, i think the women especially around our cycle time, we do tend to get more cravings for sugar, we can manage it and I’ve certainly learned to, <inaudible> magnesium intake at that time of the month is really important and there are other ways as well, I’ll share those on the blog at the later stage but this is something, this blood sugar roller coaster ride is really something we want to get under control because i find that it’s a much more pleasant place to be when we have sustained energy throughout the day and we’re not getting these blood sugar high’s and low’s and that is when we can get our blood sugar <inaudible> range.

That doesn’t mean we don’t still get peaks and <inaudible> we do, it’s natural that when we eat we do, our insulin does get raised because it’s the job of insulin to bring down our blood sugar into the tight range that our body keeps that balance in but we don’t end up getting those huge peaks and drops, we just get a slow wave throughout the day so this means that energy is all sustained. simply speaking, it’s kind of a fair lazy equation in a way when we eat healthy food it equals normal blood sugar that equals weight loss and fat burning because we’re not shutting down certain parameters in our body so all about hormones are functioning correctly that means we feel great and that means we have energy to go all day, pretty simple equation, not so easy to get right a lot of the time i know. we have so many influences around us in the world and society and that is biggest challenge for us to really focus on the needs of our selves, the needs of our bodies rather than constant messages, constant feedback that we’re receiving from our environment, from the stores we go in, from the things that are around us and that’s a very challenging thing, so we need to keep working on that and focus back on to our own. Our own goals, i guess and our own inner resolve to achieve better health and feel great on every day basis. so <inaudible> insulin a little bit more, insulin is a hormone produced by the pancreas that is central to regulating metabolism of carbohydrates also known as sugar and to a lower extent, fats as well in the body, mainly carbohydrates so the pancreas has a neuro network and along with that in the gut, that coordinates insulin release and blood sugar is the biggest influence or i should say carbohydrates is the biggest influence of the release of insulin.

Fats and amino acids to a lower extent, do produce insulin and so do other hormones such as cortisol, which is our main stress hormone actually pushes out insulin up as well so stress is also another area we need to look out for weight loss, but we won’t go into that right now. so in a proper functioning body, insulin does its job by helping to control and remove that excess sugar from the blood and our blood sugar is really very important, its kept within a very tight range in our body because insufficient blood sugar or even excess is actually life threatening. we say largely in conditions like type 1 diabetes and type 2 diabetes so type 1 actually have to have insulin  injections to maintain that blood sugar without it they essentially will die and with type 2 diabetes which is a predominantly lifestyle driven disease, it can be very life threatening too and  with both of them there’s also complications, serious complications, cardiovascular issues, oxidative stress issues, eye and kidney problems and blindness and peripheral nerve problems, i mean these things are <inaudible> to be taken lightly and yet we see them growing in epidemic proportions in society today and that’s why it’s really good to have a good graph on these things and focus on the reasons why we’re doing things.

I find that if i learn more about why, it helps me to focus more on actually maintaining those things on an everyday basis because it’s not like, oh I’ll just have to eat healthy but there are really important reasons why i want to do the things that i do every day and that is to avoid many of the common diseases that are out there, certainly doesn’t mean that we won’t get dieses all together we certainly can depending on genetics and all that type of things, that there is a lot prevention in diet and lifestyle. We’re going to talk about insulin <inaudible>, veronica and <inaudible> it’s not too technical, veronica’s asked but how about hyperinsulinemia, we just, when basically insulin is over producing and it actually occurs before a type 2 diagnosis, a type 2 diabetes diagnosis. so insulin resistance which all go into right now and talk about what that actually is but just to answer your question and all kind of incorporated into the discussion that I’m just going to end just a moment that insulin resistance occurs first and then hyperinsulinemia, that was fun that to pronounce, comes after when our cells have become resistant to the call out of insulin and then our insulin is actually trying harder and harder to deal with the blood sugar load and then once that eventually fails, we  can no longer produce enough insulin, so let me cover it to the beginning. we develop an insulin resistance as a result of sugar-insulin overload, so what happens in normal body when we eat sugar, insulin will get activated and what our body can’t use its energy and essentially out liver is dealing with that, it then stores some of it as glycogen in both the liver and the skeletal muscles where the use of energy laid up. So this is when our cells are working optimally and it’s with that <inaudible> insulin. with excess sugar and the lack of activity that most people are doing today, no activity these cell in our liver and our muscles already have full storage of that glycogen and its never getting activated and it never gets used and so what happens is these storage cells becomes resistant to the call of insulin thus insulin receptor <inaudible> that’s on the surface of those cells decrease in both the number and the efficiency of what they’re doing and so that means that that sugar is staying in the blood stream and this is where hyperinsulinemia comes in veronica. So the pancreas actually begins working extra hard, pumping more insulin because it’s trying to get the body back in balance. so this is a point in your body even if you have insulin resistance where your pancreas is actually functioning properly, it’s just over producing insulin, but there’s a problem with these is that the over activity of that insulin actually makes the insulin receptors more resistant, so its contributing to that insulin resistance and the insulin resistance prevents that glucose from entering the cells. But interestingly enough, it also prevents other things from entering cells too, like amino acids leading to building the body. so when you get insulin resistance, you may find yourself loosing muscle, may find energy levels drop, that hunger increases, you can crave more sugar, <inaudible> can start to dysfunction and maybe thyroid hormones can’t be converted properly and when that happens metabolism might slow down further because remember with these hormones, it’s a cascade of events that occurs not just one thing. so insulin resistance is like a precursor to type 2 diabetes and that at first our pancreas is actually producing insulin that’s functioning properly rather its hyper, meaning its working too much and eventually it can’t do that, it fails and that’s when our blood sugar actually is found to be in a very high range, it’s basically when our pancreas, our insulin can’t keep up with that high blood sugar load. So we can actually bring this back into balance and normalize our blood sugar again. Some people who’ve been diagnosed with type 2 diabetes have managed to get their blood sugar back to its exactly normal. We can do it through diet and we can do it through activity because we need to get those insulin receptors in the liver and the skeletal muscles throughout the body using that glycogen stores and activating those insulin receptors, so activity and diet are the two biggest things. So essentially the insulin surge tells your body to store fat and i hope that answered your question and it makes sense veronica. Sometimes my brain gets all mottled so I’m still getting much better at talking and presenting these ideas, great, I’m glad that that makes sense. So the insulin surge tells your body to store fat that’s what insulin is there to do it, it’s our energy storage hormone.

see the video at: http://vimeo.com/74335355

Hi there this is from goodfoodeating.com and today we’re going to talk about weight loss and health principles and most specifically the hormone insulin and blood sugar control and what so important with our health. so what’s we going to cover today is the endocrine system and hormones and we’re going to talk about insulin, what are these and what’s macro god health and increased weight loss results.

I’m going to look at how influences how insulin influences the body and 3 easy principles to follow if you want to lose weight and just be healthy, a basic food template to follow and also what’s next so the endocrine system <inaudible> really really fascinating topic. endocrine system is a really complex system and it corporates the actions of all of our hormones that are secreted internally and externally and these hormones control the growth and maturation in our body and metabolism which is not just how fast we burn fat but that’s what we commonly think of when we think of metabolism but metabolism of distribution of nutrients and many other processes that are involved in our body , so metabolic function, metabolic fuelling  of the body to function that’s what hormones are involved in as a major process of control and they’re also involved in reproduction as well. So lots of those major processes are controlled by our hormones and hormones essentially mean to sit in motion.

So we have to think about how these is a very dynamic system that ignites the cascade of physiological responses and that’s an important thing to remember because when in just a moment with insulin, how things get set in motion, when one thing’s occurs, its sets in motion the whole other cascaded things and essentially hormones are there to maintain balance in the body. so newton’s law of motion says that for every action there’s an equal and opposite reaction and the body always has a place of homeostasis which is basically balance and will always going to be trying to maintain it. That’s what the bottom is naturally and that’s what the hormones do.

They’re driving all of those metabolic processes, all of those things that are essentially occurring in our body 24/7 that we don’t even have to think about just quite fascinating. So our endocrine system there is are just a little picture that you can see. it’s made up of enzymes that secretes hormones, so all of these glands, these are our main endocrines glands, we have going up from the bottom of the body, our testis and ovaries, then we have our adrenal glands, we have our pancreas which is what we going to talk about today with insulin. We have our thymus, our thyroid gland, our pituitary glands, the hypothalamus and the pineal gland. So these glands, logically control although the balance in the body that we have just talked about hence, it’s ruled by the hypothalamus and the pituary gland in the brain and although these glands are the main hormone producers, we do produce hormones in organs and throughout our body as well. so, for example, the heart produces hormones, the gut produces hormones and event our fat cells produce hormones and the reason why is that hormones are chemical messengers, so the chemical messengers get activated by various <inaudible> conditions in the body and they send messages between the organs, between the glands and to the brain.

It’s a very complex system that’s driving itself and throughout what we’re doing to our bodies, our lifestyles, we have diet, these chemical messengers get activated and drive a lot of the metabolic process that happen in our body with,  that is a good or bad thing then we can influence that positively. So insulin is just one hormone we have but we have many or we could have hundreds, I’m not really sure exactly how many we have but we have many of them because as we have thyroid hormones, we have adrenal hormones. the adrenals produce over fifty different hormones on their own so we have a lot of different hormones and it is a delicate system that is largely influenced by our diet and lifestyles so we can really influence these things in a positive way, which is what we’ve all been trying to do in these detoxes, kind of bringing everything back to a level playing field something’s that’s very good to do on a regular basis. just give me give a second my, just going to close this PowerPoint and reopen it because it’s doing weird things on me for some reason it’s not giving the right slides so just trying to see if this is working better, there we go so weight loss and blood sugar/insulin, so over the entire whole objective when it comes to weight loss is generally cleaning up your diet so the foods you eat get your blood sugar to normalize and regulate.

You probably heard of blood sugar regulation before and i talked about weightless a lot, because i think it’s something that everyone generally wants to achieve a little bit more of. i don’t think its necessarily the best thing to focus on all the time, I’m much more inclines to encourage people to focus on health, however, i think that for many of us and many people <inaudible> today, just losing  some weights helps to improve a lot of our perimeters and a lot about health markers. So i do tend to rave on about weight loss quite a bit although i don’t think it’s necessarily should be our predominant focus. but generally speaking, blood sugar regulation is very important when it comes to weight loss because most people struggling with weight gain have a blood sugar that’s all over the place and we’ll talk about how that occurs and what’s the effect of that too. so when we regulate our blood sugar, it helps to promote weight loss, fat burning and optimum health because that’s how the hormones drive the body, what we’ve been talking about is that metabolic fuelling of the processes.

So when it comes to weight loss and even general health, sugar is your number 1 enemy, but not just the sugars from candy and cookies and doughnuts and things you already know but things like even fruit juices, breads, pastas, cereals, cakes most also tin goods, dairies in excess does have sugar, it’s the lactose, excess fruits, refined grains and grain products. So during the day, we talked diet, we have eliminated these main contributing factors, predominantly the sugars, even to the extent of cutting out fruit. so ways been really predominantly working on bringing these blood sugar parameters really under even kill, cleaning everything out and as we’ve seen from couple of the emails i received and also <inaudible>, is that she’s, since in wreathless, had lose couple of kilos which is around 4.4 pounds in just the one week and this is how fast the body can actually start to bring things back into focus when we just get these basic fundamentals on track which predominantly diet is the number 1 thing. so we can include whole grains and beans and legumes in our diet because these are fiber rich carbohydrates that do help to slow down that uptake in glucose in our blood stream. but generally speaking, we do want to focus on vegetables as our predominant carbohydrate source unlike, commonly into days society where we’re seem to have a bit of obsession with including everything based on a carbohydrate  base, so whether that’s a sandwich or big bowl of rice, a little bit of saucer or big bowl of pasta. We really need to begin to move away from that and focus on vegetables as our carbohydrate source and include some little bit of our whole grains and beans and legumes in there as well.

So it’s a pretty easy picture i find having a visualization is a little bit easier, from we have regulated blood sugar, essentially it just means, we’re on the ultra-fat burning zone and this is because when we have high blood sugar, it essentially stops the burning effect, it chops down various things in our body and so our body just cannot burn any fat, so it doesn’t matter what you’re trying to do, even if you’ve cut your calories down to a 1200 calorie diet which i frequently say people do, it still does not mean you’re going to lose weight, you can still be having a 1200 calorie diet and yet choosing the wrong types of foods and still have a high blood sugar which will prevent weight loss. High blood equals weight gain because insulin is our enemy’s storage hormone, it pushes fat into cells, when we have high <inaudible> we will gain weight or find it very difficult to lose weight and on the other hand, starvation and craving also equals stored fat because that’s a natural mechanism of the body, we won’t burn it because we want to protect the energy that we do have. so the blood sugar roller coaster ride at least this is what i call it, i know, I’ve definitely experienced this in my past and I’d be interested to say, if you’ve also experience the blood sugar roller coaster ride,  and essentially it goes like this, you eat sugar and you get a big peak of energy. something we don’t realize at the time is that, that excess energy is going to get stored into fat but soon after were getting a crash, we feel hungry, you can a bit lethargic so we get a big peak in energy, little do we know, excesses is getting stored as fat only to crash a little but later, we feel fatigued, we get tiredness, so we tend to eat more sugar.

So, when you rupture your Achilles tendon, and it’s done more in Europe than in this country, but not everybody has to have a complete rupture like you did.  There are ways to rehab somebody not operatively.  In this country, most people who are relatively healthy usually get it fixed.  I usually talk to people about both sides, but I think your recovery is more predictable if you fix it.  So, some people like you, if you’ve rupture it, you do okay or you don’t notice it that much.  It’s hard to tell when you see somebody.  You come in, and you ruptured your foot last week.  It’s hard to tell if that person is going to be like you, or if that person’s going to walk all the time with a limp?  It’s a little bit of a judgment call, and you talk to people about what they’re activity levels are.  Talk to them about the risks of the surgery are, and then a lot of times, they just let the patients choose.

[1:01:33]

Sometimes you can have those nodules in your plantar fascia.  The plantar fascia is when you pull your toes up, you feel that structure tighten up in your arch.  That’s your plantar fascia.  Sometimes, you can have nodules in there called plantar fibromatosis.  Usually, you don’t need to do anything about it unless it causes pain.

[1:02:15]

No, that’s a whole other talk, but diabetes is very common.  The main I would tell you is from my standpoint in orthopedics, the biggest thing that causes a lot of problems is that with diabetes you often lose the sensation in your feet.  As you lose your protective sensation, these are the people that start getting ulcers.  So, if you do all the things to maintain your circulation, there’s ways that your circulation could be improved.  We don’t really have a good way to prevent you to prevent you from getting the neuropathy or the loss of sensation.  The best advice is to first see your primary care doctor and get an early diagnosis.  The second thing is to keep your blood sugar under as tight a control for as long as possible.  That’s probably the best thing you can do to prevent the neuropathy, but if you’re diabetic, you need to be looking at your feet every day.  Diabetics don’t heal wounds the same way nondiabetics do.  They have more problems healing wounds.  So, a small blister or a small wound, even if it’s pretty minor, you have to take it seriously in treating it very aggressively to get it heal.

[1:03:45]

It depends on how deep the ulcers are and where the location is.  In people with trouble with sensation, the biggest thing is you have to stop walking on your foot.  If you have an ulcer on the bottom of your foot, it’s a pressure ulcer just like people lying in bed are getting pressure ulcers.  It’s on the bottom of your foot, and the only way to get it to heal is to take the pressure off.  So, we have wound clinics where we work in which has ways to get pressure off.  You can do it with a cast or some of these different braces or things like that.  You have to get the pressure off to get it to heal.

[1:04:30]

No.  You can live with it.  When you say reverse it, the problem is that a lot of times, you have symptoms related to it.  There’s numbness and funny feelings in your feet.  There are medicines that can dampen that.  As far as taking some medicine that restores the sensation in your feet, there isn’t anything that does that.  So, you have to figure out how to live with it and prevent the things that it can cause.  So, usually once you have neuropathy, you have to be pretty careful with the shoes that you pick.  Once you have any deformity, it’s always good to use molded inserts like a soft molded insert that goes inside your shoes.

Yes, ma’am?  Back there in the red.

[1:05:34]

That’s a bunion.  Very common.  Again the easiest thing to do is get shoes that fit your foot better.  It’s not symptomatic.  You try and modify the shoes first.  If that doesn’t work, there’s a lot of nonsurgical treatments.  You can’t really put something on the toe and hold and straight.  That may help the symptoms a little bit, but once you take it off, the toe is going to back.  So, there are certain ways to correct that.

There’s a fairly high recurrence rate in bunions, and the reason that is is that people undercorrect them to begin with.  So, you say why do people undercorrect them.  The reason is  because people with the deformities are younger people, and they’re trying to get back to work. So, they do a surgery that’s a smaller surgery so they have a quick recovery.  Sometimes that will help for about 5 years or so, but as you get older, the toe starts going back over again.  So, if you undercorrect the deformity, there’s a high chance it’s going to come back, but if you correct it all the way, it does very well.

Yes?

[1:07:15]

Pain in the ball of your foot, like under your big toe?  The second toe?  Yeah.  Usually, that’s related to the joint, your metatarsal-phalangeal joint, or MTP joint, where the toe meets the foot.  As that gets tender, usually people with longer metatarsals have more pain because that’s the area where most of the pressure concentrates when you go up on your toes.  It’s the first stage of hammertoe.  That joint gets irritated.  The treatment for the most part if you get a good arch support, you can probably relieve a lot of the symptoms.  If you have a deformity of the toe, there’s some little things you can put in your shoe.  If your toes are getting cocked up like that, there are little things you can put on your shoe that let your toe lay down, then that redistributes the weight off the pad into the arch of your foot. So, if you don’t have a big deformity and you’re not having a problem with your shoe, usually you can treat that within inserts or some type of arch support.

Yes?

[1:08:34]

We’re trying to answer both those questions with a research study.  Most of the people who get better get better within a month or six weeks.  They’re seeing the difference.  We don’t really restrict them a lot.  Obviously, it does hurt to get a needle jabbed into your Achilles tendon, again we do it on Friday afternoon.  I tell them to put ice on it and take it easy for about a week, but I don’t really restrict them more than that.  There’s no boot or brace you have to put them in.

The way our study’s working is we have to fill out these pain scores before they do it.  Then, we get the pain scores at two weeks, four weeks, six weeks, three months, and a year, and the success rate of all the people we’ve put in our study is we haven’t had to do surgery on any of them.  There aren’t people there giving me a hug in two weeks saying this is the greatest thing they ever had, but on the flipside most of them are saying they feel better.  Fifty, 60% of them say they feel better to the point where they’re not going to physical therapy.  They’re not doing a shoe modification, and they’re not wanting to do surgery.

So, what we’re to try and follow them for a while and find out whether it’s a lasting effect, but for the cost of one injection and no hospitalization and no surgery, there’re really no loss time from work.  I think it’s really a reasonable option.

Yes, ma’am?

[1:10:28]

No, like in the back of your lower leg?  Like along your Achilles tendon?  Stretching is good.  For Achilles tendon problems, one of the things that we promote is a thing called negative stretching.  It’s basically, if it’s my left foot that’s affected, you stand on a step.  You go up on your toes on both feet.  Then, you shift your weight all the way to your left foot.  Then, you go all the way on your left foot and you slowly go down.  It gives you an eccentric muscle, and the theory is that it’s supposed to be better for the tendon.

Yes, sir?

[1:11:28]

It’s on the top of this foot?  No change in alignment of this foot?  Yeah.  Both feet. This is like a collegiate competitive runner?  Does it ever prevent him from running?  I’d probably just cross train him as much as I can.  I don’t know, probably an overuse issue.  Just cross train him as much as you can, especially if it’s both feet.  That goes against an injury.  Get him a bike.  I think you stumped me on that one.

Yes, ma’am?

[1:13:17]

In general, if all you’re doing is the first toe, my standard answer is it takes about 2.5, 3 months to get you back full time in a shoe.  So, usually you’re protected weight bearing with crutches for a full month.  You start putting more and more weight on it.  By three months, you should be on a shoe.  Again, the success rate is related to the initial correction that you get.  I think the struggle making your decision on a surgery is depending on the deformity, you have to choose a surgery that will fully correct the surgery.  You have to be realistic.  I’m not one of those guys that tells you to do this surgery and you’ll be back to work and running in a month.  It’s not really worth it to go through surgery if you don’t fully correct it.  I mean, because you’re going to be doing it again in 10 years.

Okay. Oh, yes?

[1:14:29]

I think the ibuprofen is mainly for pain.  I think the anti-inflammatory effects have been overly promoted.  It’s not going to help you with swelling.  The main reason you take it is for pain.  The main risk is stomach problems.  So, you have to be careful if you’re prone to get ulcers in your stomach or if you have stomach upset or reflux or things like that.  You have to be careful with the anti-inflammatories, but it’s one of the most common medicines prescribed.  It’s pretty safe.  You’ve got your Tylenol® and Aleve® and Motrin®.  You can’t take Aleve® and Motrin® together.  They do the same thing.  Tylenol® is a different kind of medicine.  So, you can mix Tylenol® with Motrin®.  You can mix it with Alve®.  Don’t mix Aleve® and Motrin®.

Okay.  Yes?

[1:15:39]

You mean the wound doesn’t heal? Was it like surgery for a broken ankle?  There’s a lot of reasons why bones don’t heal. A lot of it has to do with the severity of the injury.  It has to do with how it’s fixed.  Sometimes, the alignment of the foot can affect whether it heals or not.  Most ankle fractures heal.  Perhaps the biggest problem we have with ankle fracture is it’s a little bit stiff afterwards or it’s a little more prone to arthritis.  If it doesn’t heal, I think the first thing you have to look at if you had surgery is how you fixed it.  Sometimes, either you didn’t put enough screws in, or you didn’t fix it stable enough for the bones to heal.  Diabetics in general have more difficulty in healing bones.  So, there’s some medical reasons why fractures don’t heal.

[1:16:58]

I would think that would be unusual.  So, there would be some reason that you want to look for that’s fixable so they can walk on it.

Yes?

[1:17:22]

Microscopic in the sense that you use a microscope to do it? Now, the main areas are used a lot in spine surgery.  It’s also used a lot in hand surgery or where you’re reattaching vessels or things like that.  I’m not sure if you meant arthroscopic which is a way of looking inside joints.  So, mostly in the ankle, you do arthroscopic surgery, but not necessarily microscopic.

Alright.  Well, thank you for coming out.  It’s been a pleasure talking to you.  Usually, when I have these things, there’s always leftover food.  So, feel free to grab a bottle of water and a cookie for the ride home, and that way, we don’t have to take them out.

Thank you for coming, and if you have any questions, I’ll be happy to talk to you later.