Sunday, December 6, 2009

Making a Man Out of Mac (continued)

It turns out that much of what we need to do to get in better shaped is 
linked to when we choose to eat relative to our workouts and during the 
course of our day.  The following posts were provided by my friend Jon 
who has  designed a game plan for getting the most out of our workout 
and eating schedules.  If you have the discipline to keep to a schedule 
you can accomplish more with shorter intense workouts.

There are so many options when it comes to food that you could eat a different food every time you eat something for the rest of your life. Same goes for drinking options.

You crave certain foods. If you are like most people, you tend to crave foods that are not typically helpful to weight loss and fitness efforts.

Yet most of us still want to lose weight (or at least maintain our current weight) and be more fit.

These are the reasons why most restrictive diet plans fail and exactly why EET has been designed with the key guideline that your eating plan has to be customized to fit your lifestyle and will include the foods you crave.

EET is not trying to change your food cravings, as if they are something bad or harmful. In fact, EET has a tremendous respect for the foods you crave. These cravings are part of your body's current metabolic memory and they are sending you a message that there is SOMETHING about these particular foods that is positive for you.

There are many possibilities to explain your food cravings. Maybe it's emotional, eating the foods you crave make you feel better. Maybe it has to do with your body's unique chemistry, the foods you crave might give you more energy or maybe your body just really wants to experience the particular taste of the foods you crave.

Whatever the exact reasons are, EET is clear about what the reasons for food cravings are NOT:

It's not that you are undisciplined, or unhealthy or that everything you want to eat is bad for you. That's what the existing world of diet and exercise plans would have you believe.

So food cravings are good, and your weight loss and fitness plan should be built around them, because if you satisfy these cravings and can still meet your weight loss and fitness goals, you are very likely to stay with such a plan. EET is such a plan. Possibly the only plan that will allow you to enjoy the foods you crave, every day.

Does EET's approach to embracing food cravings have risks? Yes. You have to learn when your body can best handle the foods you crave, so there might be times you have to wait to eat the foods you love, but you never have to wait for long. You have to learn to control the portions of the foods you crave, and some people are not good at that. However, like many of life's great benefits, too much of a good thing can be harmful. Take water and electricity as examples.

Correct amounts of water are among the healthiest items you can include in your diet (if you time it right). Too much water can be very harmful or even fatal.

The correct amount of electricity to meet your needs is one of the most helpful items in our lives, yet too much electricity is very harmful or even fatal.

We don't suggest people live without water or electricity, instead teachers explain how and when to use them to their greatest advantage. This makes them wonderful, positive parts of your life.

Teachers of EET have the same approach to the foods you crave the most.

Jon Pearlstone, age 46, is the founder of the EET Fitness Plan. He has lost over 30 pounds in the last 19 months eating the foods he loves and exercising less than 30 minutes per day 5-6 days per week. For more information on EET contact Jon at

Here's a before and after picture update of Jon since his original post in Sept 2009:

May 2008 200 LBS

Sept 2009 176 LBS _________________ Dec 2009 168 LBS
________________________________ (Right after T-Giving!)

Monday, November 16, 2009

Saturday, November 14, 2009

Barefoot Running on MSNBC Dr. Nancy Snyderman

Friday, November 6, 2009

Core Exercises


Intermediate/ Advanced:

Monday, October 12, 2009

A 4 minute Workout to Max Fat Burn and Conditioning

If you are traveling on the road or have kids , here's one way to never have an excuse not to work out again. Thanks to my friend Jon for sharing his research.

Thursday, October 8, 2009

Bike Fit

My friend Paul put this article together:

If you buy a suit don’t you have it tailored? When you buy new tires for your car you have them balanced, right? When you get glasses you have a doctor examine your eyes to get the correct prescription. The last time you bought a new bike did you have a proper bike fit performed?

This article will explain all the specific measurements that should be taken in a bike fit and how to best make changes to your bike that correspond to those measurements. It will also explain why most people will need treatment to resolve muscular imbalances and flexibility issues.

Too often many people set up their bike by the way it feels to them only. If you have a bike fit completed not only will you be more comfortable on your bike but you will also perform better and reduce your chances of injury. When having a bike fit performed there are specific measurements that should be taken. The measurement that is most important for power production in the angle of knee bend when you are at the bottom of your peddle stroke. Besides this you also should know your hip angle when holding your handle bars in the position your most often ride in which should be on the brake hoods. The fore-aft position of your knee in relation to the pedal and the amount of sway of your knee during your pedal stroke are all important to power production and comfort on your bike. Cleat placement is also important. Other smaller changes that can affect your optimal position on a bike are saddle size, handle bar size and fore-aft position of the saddle. One aspect to an average bike fit that I think is missing is testing a person’s flexibility and strength. Most bike fitters don’t have the knowledge of how to accurately test someone’s flexibility. Even if the fitter does know how to, no fitter is able to treat those issues.

As I stated earlier the single most important measurement that will be taken during a bike fit is the angle of your knee at the bottom of the pedal stroke. Research has shown that the knee should flex optimally to 35 degrees to produce the greatest amount of force. This can be easily measured using a goniometer. A goniometer is basically a protractor that can be centered at the knee joint with each arm running along the shafts of both the femur (thigh bone) and fibula (shin bone). By lifting your saddle up as little as 2-5mm you can decrease the angle of knee flexion. What if you have an inability to straighten your knee to that degree because of extremely tight hamstrings? No alteration of your bike settings will allow you to have an optimum pedal stroke. This is why you need to check flexibility and then have treatment performed on your hamstring. Soft tissue techniques like Active Release Technique and Graston Technique are perfectly suited for a situation like this. These techniques are what we often use for treatment at Capital Sports Injury Center.

The angle of your hips will be the second most important measurement taken during a bike fit. The smaller the angle of your hips are the more aerodynamic you can become on your bike. With less of an angle you can get your upper body closer to parallel to the ground causing less wind resistance. This angle again can be measured with a goniometer using your femur and the midline of your abdomen centered about the hip joint. The correct angle to use depends on the rider. Are you more interested in comfort or aerodynamics? An aggressive rider would want something around 25 degrees while someone looking for more comfort would do fine closer to 30 degrees. The measurement of this angle is even more dependent on flexibility. A person may have tight erector muscles in their low back or tight hamstrings that don’t allow them to rock their pelvis forward. Even if a rider wants to be aerodynamic they would never be able to sit in that much of a tucked position.

The fore-aft position of your knee can affect the amount of knee flexion you can accomplish at the bottom of a pedal stroke. If your knee is too far forward the amount of flexion will be increased at the bottom of the pedal stroke and vice versa if your knee is too far back. Riders may also be shifting forward on their saddle either for comfort or extra power. This will change all the measurements. It is important to have the rider sit on their saddle correctly.
That brings me to a problem that I had previous to my bike fit. I was sitting on a saddle that was too narrow. This meant that I was not sitting on my ischial tuberosities (sit bones) but was rocking forward onto my pubic bone. As you can guess this was not very comfortable. The average size saddle is 130 mm wide at its widest point. If you are a larger rider chances are this will not be large enough for you. No amount of change in the different parameters of a fit will help if you can’t sit on the saddle correctly.

Cleat position is closely tied to knee sway most of the time. If your cleats are set up so that you have no movement at all or you will clip out your knees will have to sway more if there is a hip problem. Having said that you can make up for hip issues or increased knee sway if you increase the amount of internal rotation of your cleats. By doing this you can increase the internal rotation of your foot and allowed your knee to track straighter up and down.
Although not often an issue the size of your handlebars can be problematic with shoulder injuries. If you have had an injury where you have lost the ability to extend your arms or internally rotate them you may need a larger handlebar. With any shoulder injury some form of treatment and exercise should be performed to help recover the lost movement. A great internal rotation exercise can be performed with tubing. Start with the tube attached to something on one end and grasp the other end with your thumb up and arm abducted (away from your body). Facing perpendicular to the tube internally rotate your arm so that your thumb is down and reach behind your back to the opposite shoulder blade.

The final aspect to a bike fit may involve changing the fore-aft position of your saddle. When this is done it move your entire body either forward or backward. This is usually done when a rider’s knee fore-aft position or knee flexion at the bottom of a pedal stroke can’t be fixed with any of the other bike fit components.

One aspect to a bike fit that is typically missing is testing a person’s flexibility, caused by imbalance, and strength. This is called a functional movement screen (FMS). Since most bike fitters do not have this expertise, Drs. Horwitz and Glodzik add the FMS to help the bike fitter make the best decisions on equipment and placement. These imbalances cause compensatory changes in multiple areas of the body resulting in "energy leakage" and increase the potential for injury. As in the example above, if your hamstrings are tight, this may be due to weak gluteal and core muscles as well as due to adhesions in the muscle itself. A corrective exercise program and a program of care to resolve these issues must be undertaken. This will certainly change the bike fit! Even with all the different changes that can be made to make your bike more comfortable riders still need to fix the problems that are necessitating the changes. A rider should have their injuries treated and still perform other training off the bike to make it easier to be on the bike.

For any questions feel free to contact chiropractors Drs. Horwitz and Glodzik at If you are interested in a bite fit or are experiencing any other problem and would like to make an appointment in our Silver Spring, Cleveland Park, or Georgetown offices, please call us at 301-622-9000.

Tuesday, September 29, 2009

Successful Junk Food Diet Shakes Up The 2% Club

My friend, Jon Pearlstone, from I.U. put this plan together over the last year and has had success with it so I asked him to write about it for us.

Jon is a self taught fitness expert who, among other things, took up the Javelin at age 41 and made the State Finals of the California Community college Track meet as a by age 43. Now 46, he has used his experience, his sons' UCLA track and football experience and a lot of research to devise this plan. The version of EET he writes about here is for people who want to get lean and stay lean.

Personally, I'm getting involved with Jon's other version of EET. It's a Body Building Program to bulk up, get more muscular and fit I am hoping it helps with the upcoming triathlon season. I will keep you updated and let you know how it goes. In any case, his plan is different and interesting and worth reading about.

Successful Junk Food Diet Shakes Up The 2% Club
by Jon Pearlstone

It’s nearly impossible to get in, and has nearly 50 million applicants every year. Only the 2% of dieters who maintain their goal weight for over a year are admitted: It’s the exclusive “2% Club”.
For 20 years I stood outside the Club’s velvet rope with the masses only to get shot down again and again. Meanwhile, the spare tire around my waist kept growing.

But, my years of struggling ended this year thanks to my new approach to dieting. I lost 20 pounds and kept it off while eating junk food everyday. You read that correctly, EVERY DAY. Here’s my before and after pics and my story: May 2008 200 Pounds

September 2009 176 Pounds


Through the years, I paid $1000’s to the 2% Club’s membership agents, including Weight Watchers, Atkins, Protein Power, and endless health club fees. Each effort had the same sad story line. Lots of hype and some success for a short time, followed by the “rebound” right back to where I started. Then, the painful torture of tacking on even more weight.

Then, last year at age 45, tipping the scale at 200 pounds for the first time, I was sneaking into the fridge to enjoy my 3rd Dairy Queen Dilly Bar of the day, and it hit me.


At that moment, I knew the challenge I had to accept. To join the 2% Club by finding a diet plan that let me eat junk food and still lose weight.


I have zero willpower when it comes to eating, but I was prepared to increase my exercise if it meant I could eat my beloved Dilly Bars, BK Whoppers, and other fun foods. Just need to exercise more to pay for my weakness, right?

Uh, no. Multiple reputable sources made clear that nutrition is the key to weight loss, PERIOD. The evidence suggests that exercise is about 25% of the formula for losing weight, and too much exercise can even cause weight GAIN due to muscle fatigue, stress, and other reasons.

Great. Now I had to lose weight while eating whatever I want and exercising LESS. Cue the laughter from the folks at the 2% Club’s juice bar.


Amazingly, the very next day, fate intervened. My teenage sons walked into the house with a bag full of McDonald’s Cheeseburgers. AND DINNER WAS ONLY AN HOUR AWAY!

I remembered eating like that back in the day, and I never gained weight. It’s that insanely high teenage METABOLISM. Bingo! All I needed to do was to reset my metabolism to act like a 17 year old and that 2% Club membership was mine. Good Luck with that.


I saw no way to reverse the aging process and have a teenager’s metabolism. But, while studying other ways to reset and accelerate metabolism, I found a question that completely changed how I approach fitness. (I am paraphrasing):

Would you gain more weight if you ate 10,000 calories of chocolate for breakfast or right before bedtime?

Most agree that eating 10,000 calories of chocolate for breakfast will result in less weight gain than eating it right before bed as you have more “active” time in the day to metabolize it. The same concept made sense to me for exercise as well. Could eating and exercise timing be just as effective at less extreme examples? I was sure it could and was determined to prove it.


There’s months of research and lots of details behind my EET Fitness Plan, but, here are some key points and an outline of how EET works:

After exercise, when you have completed breaking down your muscles your body goes into “recovery mode” and ramps up it’s efforts to recover and rebuild. This creates a “metabolic window” if performed and timed correctly.

In addition, Dr. John Ivy of the University of Texas is his groundbreaking book Nutrient Timing, The Future of Sports Nutrition (2004) found that when a metabolic window is created, muscle recovery was most successful when HIGH GLYCEMIC CARBOHYDRATES were eaten along with protein (p.61).

To Dr. Ivy, high carbs meant something like a supplemented protein shake. To me it meant DILLY BARS and the wonderful world of junk food. (Let me be clear, my EET plan is very different from many of the suggestions in Dr. Ivy’s book and Dr. Ivy should not be considered affiliated with the EET plan in any way.)

I utilized the above information with other well supported findings, such as burning 3 times more fat in the morning that at any other time during the day, and how to best time eating a variety of foods day and night when the metabolic windows are closed. I also found studies with highly effective workouts which could be completed in under 30 minutes while maximizing fat burning throughout the day. By combining of all this and more, the EET Fitness Plan was born.


As I write this, it’s now been 17 months since I have followed my EET plan, and I am now a card carrying member of the 2% club.


But, it’s not just about junk food. EET let’s me live a normal life that includes junk food. I also go out to lunch and dinner a few times a week, more during holidays and vacations. The difference is I have lost weight doing these things!
And for you naysayers from the 2% club that say a fitness plan that includes junk food has to be bad? I say you can’t help what you love. I’m sure I’m not alone loving foods that are considered bad for weight loss when I drive down street after street filled with fast food, bakeries, ice cream parlors, fancy restaurants and a lot more. All of these would kill any conventional diet. For me (and other 98%ers) it’s crazy to have a plan that doesn’t accept this reality.

And who knows if junk food is all that unhealthy? Some studies show junk food reduces stress. Maybe it’s keeping me healthier? Bottom line: I haven’t missed one workout in 17 months due to illness or injury, so you be the judge.

Last but definitely not least, let’s talk money. Here’s the cost to follow EET:

* SUPPLEMENTS $0 I take no supplements of any kind
(vitamins, fat burners, etc.) these can be riskier than junk food IMHO
* FOOD COSTS LOWER No prepackaged plan foods here. I
buy what’s on sale and make it work.

So much for the 2% Club’s mantra that you can’t lose weight without “investing in yourself”. I have now proven that you can actually lose weight and keep it off without spending a ton of money and I’ve cut my exercise time in half!


I’m happy to finally be in the 2% Club, but there’s no lifetime guarantee. I will say my results to date certainly are encouraging for a longer term stay.
And, to help others and keep me motivated, I’m teaching the EET Plan to people who have yet to find a way into the 2% club. If I have my way, people will no longer have to apologize or feel guilty for loving to eat..

Jon Pearlstone is currently continuing to test and improve his EET Fitness Plan. He is offering trials of his EET Fitness Plan at no cost. For more information on EET and any questions or comments, Jon can be reached at

Monday, September 7, 2009

Remembering 9-11

Standing on the viewing platform of the World Trade Center site, I was not fully prepared for the deep emotions I experienced nearly six months after the devastation. In March of 2002, I spent a weekend volunteering at the medical clinic located in St.Paul's Chapel, which was spared by the September 11 blast and served as the immediate triage station after the disaster. The chapel continued to serve as a medical clinic and source of refuge for the firefighters, police officers and recovery workers. Before my shift began, I went to the excavation site. Around the perimeter,the heat-seared midsection of a skyscraper served as a painful reminder of the lives lost. Huge banners lined Broadway, honoring the firefighters and police officers for their heroic acts. Shrines set up by the victims' friends and families surrounded the chapel.
Inside the chapel, the clinic coordinator explained that the workers sought relief not only for their feet; they needed someone to talk to. The chapel also served as community where workers could pray, rest on cots, or have a warm meal served by volunteers. The spirit of the police officers there spanned all emotions. Many officers shared jokes. Others, more solemn, sat reading children's letters of encouragement. One officer was stoic until a group of children sang and then hugged each of the civil servants in the chapel. I'll never forget how he let go of some of the pain if only for a few moments as he closed his eyes and smiled in their embraces.
The people I treated appreciated the convenience of having care available at a moment's notice. Most of my patients worked grueling 12-hour shifts. Some workers improvised their own podiatric supports: one construction worker came in limping with a makeshift splint made out of tape slung from behind her heel to the base of her toes, holding them upright.

Near the end of the shift, a protocol officer asked me if a calling had brought me to the clinic. I told him I considered it a privilege to help make his fellow officers more comfortable. While reflecting on the conversation on the drive back to D.C. I thought about my friend Jimmy from college who made it out of one of the towers on the march down the stairs and a doctor from Arlington I knew with a young family on a west bound plane who did not. I thought about my cousins who I stayed with across the river in Brooklyn who were living with the traces of the aftermath in the faces of their friends and neighbors. It occurred to me that the "calling" he was talking about is the reason most of us in healthcare embark on a career in medicine. Sometimes it takes an experience like this to remind us why we started the journey in the first place.

Tuesday, August 18, 2009

Thinking Outside the Box

Thinking outside the box is thinking outside traditional boundaries. . Management guru Mike Vance has claimed that the use of the nine-dot puzzle in consultancy circles stems from the corporate culture of Walt Disney . The phrase relates to a traditional management problem called the nine dot puzzle. The object is to connect the nine dots with only four lines. (solution at end of post)

Houston, We Have a Problem

Remember the movie Apollo 13, where the survival of the crew literally depended on fitting the square central module carbon dioxide scrubber canisters into the round holes of the lunar module unit and unless a way could be found to use the square ones the carbon dioxide levels would reach poisonous levels before the crew could get home. The solution came in the form of jerry-rigged duct tape, suit hoses and cardboard to make the connection. Their problems still were not over as they had to shorten the trajectory back to the earth with damaged navigational equipment and had to use the sun and crescent of the earth as reference points for their second rocket burn back.

In the world of sports John Madden redefined how people relate to football with his X's and O's on the telestrator. He made the technical aspects of the game more accesssible to the average viewer. He made the viewer more connected with the humor he injected in his telestrator such as steam vent lines off a bald player on the sidelines and circling old school barbeque at the cities he visited on the road. Known for his zingers on the air, perhaps his most profound quote was:"Coaches have to watch for what they don't want to see and listen to what they don't want to hear".

Olympian Gary Hall Jr. took the monotony of training laps in a pool outside the box devising his own training schedule which included spear fishing,boxing yoga and racing with swimmers from other countries at his base camp. Bucking the traditional Olympic development training model, he brought the training to his home on terms that worked for him so that he was able to compete successfully at an elite level while navigating through the meticulous monitoring needed with managing his diabetes.

In football, Redskin coach Jim Zorn has a reputation for being outside the box with unusual training methods such as the use of both Slip 'n Slides and Dodge Ball drills in his football practices. He once bought in a baseball player to teach his quarterback how to slide. He has manged to continue to earn the respect of outside of the box players such as Chris Cooley. He took a very unorthodox approach to the NFL code of private critique and public praise when he called out some players that were not playing up to snuff. Being candid about his players' performance level is something that is important for a unit to respect its leader in high risk situations according to Thomas Kolditz head of the psychologic testing
at West Point. In an office setting calling out staff is in public is not constructive. The critical difference is that shared risk mandates that decisions made on the football or battlefield have to happen in a very narrow time frame and the physical well being of your teammates and fellow soldiers depends on tight integration and performance of the unit. The Redskins record this year is not a
reflection on the coaching as much as the influence of upper management and injuries. An organization is ultimately only as good as its top brass.

Tuesday, July 28, 2009

Swimsuit Technology The Car & the Driver

Its the car and the driver these days in swimming with the advent of super buoyant suits.

Saturday, July 25, 2009

Stretching Revisited

Recently, a New York Times article summarized some research by the University of Nevada that concluded that static stretching for 30 seconds decreased muscular power of the hamstring and quadricep muscles of those that stretched before activity versus those that did not.1 The decrease was about 3%, minimal but not insignificant, particularly when fractions of a second can count in sprinting events. Vertical jumping height and torque were unchanged. Power is the application of work within a finite time. Torque is the application of force and does not require movement unlike work. Torque is the force you apply to a jam jar that is stuck. Work is what happens once you get the lid moving.. Similar reductions were found in the Achilles tendon in a previous study.2 Two other studies reported that strength was reduced up to one hour after static stretching.3

It is important to remember that athletes have different requirements depending on the sport and stretching should be sport specific. "Athletes typically include static stretching as a part of the warm-up, but the evidence is clear that this practice will decrease performance in sports that require explosive movements," said UNLV kinesiology professor and study co-author Bill Holcomb, who directs the university's Sports Injury Research Center. When I asked Bill Holcomb to elaborate on his conclusions he said “The type of stretching to warmup should be dynamic rather than static to prevent a reduction of power. Then, after activity and during the cool down, static stretching can be used to improve range of motion/flexibility for later performance.“ Warming up is also something that can be overdone at the expense of performance.

“There is a neuromuscular inhibitory response to static stretching,” says Malachy McHugh, the director of research at the Nicholas Institute of Sports Medicine and Athletic Trauma at Lenox Hill Hospital in New York City. The straining muscle becomes less responsive and stays weakened for up to 30 minutes after stretching. Another support to the idea of the inhibitory response is that the other side of the stretched leg has been shown to have less power. Stretching muscles while moving, on the other hand, a technique known as dynamic stretching or dynamic warm-ups, increases power, flexibility and range of motion. Muscles in motion don’t experience the inhibitory response. They instead get what McHugh calls “an excitatory message” to perform.

Much has been written about problems with ballistic stretching but dynamic stretching is different. Dynamic stretching consists of controlled leg and arm movements that extend to the limits of your range of motion. Ballistic stretches involve trying to force a part of the body beyond its range of motion. In dynamic stretches, there is no bouncing.
Flexibility is speed specific. There are two kinds of stretch receptors, one measures magnitude and speed and the other measures magnitude only. These receptors are also responsible for the stretch reflex, our body’s protective mechanism, which counters in the opposite direction to the part being stretched. This also explains why it doesn’t make sense to static stretch prior to dynamic activity. There is considerable but not complete transfer of static stretching to dynamic stretching.4 In another study that looked at static stretching done not in close proximity to testing, on groups that were doing no other training regimen, the stretching group performed better. The author concluded that stretching in this manner could help bridge to a regular training regimen.5

Citing earlier studies, Stacy Ingraham, an exercise physiologist at the University of Minnesota, Twin Cities, says that, "When you stretch, you lengthen muscle fibers. It then takes longer for messages from the brain to travel through them. Stretched muscles also seem to be more sluggish than un-stretched ones. They don't spring back as readily. And every time you stretch, you may be tearing your muscle fibers a tiny bit."

The epidemiology program office at the Centers for Disease Control and Prevention conducted a study that reviewed 361 research studies on stretching. The results indicated that stretching increased flexibility but this did not decrease injury rates. Injury rates were higher for both the most flexible and least flexible study participants than for those in the mean.6 I have talked with athletes and yoga instructors about overstretching before explosive sports such as soccer and the possibility of too much laxity creating instability and a setup for injury. This would likely hinge on the flexibility of the athlete at baseline. Witvrouw et al believe that part of these contradictions in injury rates of studies can be explained by considering the type of sports activity in which an individual is participating. “Sports involving bouncing and jumping activities with a high intensity of stretch-shortening cycles (SSCs)(e.g. soccer) require a muscle-tendon unit that is compliant enough to store and release the high amount of elastic energy that benefits performance in such sports. If the participants of these sports have an insufficient compliant muscle-tendon unit, the demands in energy absorption and release may rapidly exceed the capacity of the muscle-tendon unit. This may lead to an increased risk for injury of this structure.” They add that recent studies have shown that stretching programs can significantly influence the viscosity of the tendon and make it significantly more compliant for the rigors of high intensity sports.7

How do these findings relate to some of our concepts of treatment? In 2002, Lance Barry, DPM reviewed static gastrocnemius-soleus stretching versus night splints in the treatment of plantar fasciitis. He found that the night splint group had a significantly reduced recovery time. The idea of putting the fascia at physiologic tension versus stretching the gastrocnemius had more of an impact on improving plantar fasciitis. Immobilization, a time honored strategy is part of the treatment with night splints. The splints that extended the toes, in this case the Strausberg Sock, had better results than the other splints although this variable was not part of the study design.8The parallel between these studies is that muscle static stretching just prior to activity does not promote better sports performance and runner's style static standing stretching for plantar fasciitis may damage the fascia and delay healing.

Naturally, there are many variables to consider when determining the best options for athletes and our patients regarding stretching. The evidence leans towards more dynamic stretching as part of a warm up routine in lieu of static stretching immediately prior to activity.

1.Samuel, MN, Holcomb, WR, Guadagnoli, MA, Rubley, MD, and Wallmann, H. Acute effects of static and ballistic stretching on measures of strength and power. J Strength Cond Res 22(5): 1422-1428, 2008
2.Rosenbaum, D. and E. M. Hennig. 1995. The influence of stretching and warm-up exercises on Achilles tendon reflex activity. Journal of Sport Sciences vol. 13, no. 6, pp. 481–90.
3. Fowles, JR DG Sale, JD MacDougall - Journal of Applied Physiology, 2000 - Am Physiological Soc. Vol. 89, Issue 3, 1179-1188, September 2000 Reduced strength after passive stretch of the human plantarflexors
Kokkonen et al. (1998) Research Quarterly for Exercise and Sport
4.Kurz, Tomas, Science of Sports Training, page 236
5.Kokkonen AG Nelson,C Eldredge, JB WInchester - Medicine & Science in Sports & Exercise , 2007 1831. Chronic Static Stretching Improves Exercise Performance.
6.Pope, RP, Herbert, RD, Kirwan JD, Graham, BJ A randomized trial of preexercise stretching for prevention of lower- limb injury. Medicine and Science in Sports and Exercise. 2000; 32:271-277.
7.Witvrouw E, Mahieu N, Danneels L, et al. Stretching and injury prevention: an obscure relationship. Sports Med 2004;34:443-449
8. Barry, Lance D. DPM et al. "A Retrospective Study of Standing Gastrocnemius Soleus Stretching versus Night Splinting in the Treatment of Plantar Fasciitis," The Journal of Foot and Ankle Surgery, Volume 41, Number 4, July/August 2002.

Tuesday, June 23, 2009

More Barefoot Running Info

The following is some feedback from barefoot runner Ken Bob:

I enjoyed reading your post. Though it doesn't have any new information, it is a good round-up of the general issue.

I would add, that in the book, "Barefoot Runner"
One of the reasons (may have been speculation on the part of the author) given for Abebe Bikila wearing shoes in the Tokyo Olympic Marathon, was so as not to dishonor his hosts, who presented him with the new shoes. I will be among the first to admit, that Abebe Bikila comes off as a bit naive in this account of his life.

As far as the arguments for support, or feedback - in engineering, any system that benefits from feedback, will be more stable than one that cannot sense it's own outcome. The problem I see with Robbin's and other's writings, is that they are written by doctors for doctors. Running barefoot is very simple. It provides precise feedback, via the thousands of nerve endings in our soles, that help us learn (if we take the time to listen) how to run more gently, and more efficiently.

As for runners who wear shoes because they have problems running barefoot... I suspect the opposite is more likely true, as many of the folks on my email group, have started running barefoot because they could no longer run with shoes. In our society, I suspect there are only a few who would give running barefoot a fair chance, until just these past few months, thanks to Christopher McDougall's book. The problem is, most of us have learned to run, without the benefit of the precise feedback from our soles, and so, if we simply step out of our shoes, and attempt to run the way we ran with shoes, which has in many folks, become a very strong habit, we will say, "Running barefoot hurts!" What we don't realize is that pain is trying to teach us to change the way we run. But, old habits are difficult to break, and few folks want to make changes in their lives, when they can simply pop a pill to kill the chronic pains they suffer from years of poor running technique. And most won't even try running barefoot, especially if it already hurts to run with shoes. So, I suspect, there are a great number of would-be runners, who have given up running, simply because the idea of running barefoot had not occurred to them, or they cannot imagine how it could possibly be better than with shoes.

While many of those who have given it a fair chance, like Barefoot Ted, who could not run more than a few miles with shoes, without severe pains in his knees, back, etc... Now, since he took the time to relearn HOW to run, while barefoot, has successfully completed, not just a few marathons, but also several ultra-marathons, up to 100 miles!

And Ted is not a rare exception, except for his interest in ultra-running and an eagerness to talk, both of which has given him some fame.

Some ten years earlier, there was another runner, who wanted to run, but had all sorts of knee and back pains whenever he tried any significant distance with shoes - and he had tried all sorts of shoes that were supposed to solve these problems. He found my web site, and being a registered nurse, was not only skeptical, but made it his mission to prove me wrong. Now we call him, "Barefoot Larry" and he has completed dozens of marathons, all barefoot.

Well, I could go on and on, but I think you might be better served by asking some specific questions, and I would like to express my gratitude that you, as a DPM, are actually showing an interest in this issue, for as a wise person once wrote, "Some will experience cognitive dissonance when their point of view is challenged." And for a long time, this has been our experience with foot doctors.

I am just another runner, who finding it difficult to run any significant distances in shoes, without ending up with bleeding feet ( I am a rarity in our society - one who never really adapted to running with shoes ), started the Running Barefoot web site, as a means of answering the many questions folks were asking me, anytime they saw, or heard about me running barefoot. I never intended to take on the shoe industry. But, I am happy if a few folks have begun questioning the accepted wisdom of seeking solutions from those whose business is to profit from the same solution. Now, I'm not opposed to making profit, after all, I too work for a living. However, I do believe we, as a society, need to be much more critical of marketing strategies, particularly, in realizing that they ARE marketing strategies, not necessarily gospel truth!

Have fun,
-barefoot ken bob

Monday, June 8, 2009

Saul Raisin: Coma to Comeback Road to Ironman

I met Saul at the Clarendon Cup Bike Race this year and how could you not get drawn in by his story. I'm half way through his book and wanted to share some of his thoughts moving forward. Forget Tony Stark, Saul; you're the real Ironman, brother.

A little over three years ago I lay comatose in a French hospital. I almost lost my life. My massive brain injuries were the result of a high-speed bicycle crash. My parents stood at my bedside, trying to comprehend the prognosis. They were told by doctors that I could be possibly brain dead, if I was to live they needed to find a nursing home to put me in because I would need special health care assistance the rest of my life. At the time I am told that I was the youngest team leader ever in the Sport of Cycling. At the age of 23 my future in cycling could not have been brighter. In the blink of an eye my world changed. In that same instant, though I couldn’t possibly comprehend it at the time, my life gained real purpose.

Doctors have called my recovery miraculous. Within the last three years I’ve raced in the US Pro Cycling Championship, run the New York City Marathon,Married and Divorced within 8 months, and competed in several Triathlons. I told my friends and family when I was in the hospital if I ever lived a normal life again that I wanted to give back and help people like me. Now I have started the Raisin Hope foundation and I’ve written a book to let others know that they are not alone. If I am not giving motivational speeches to crowds numbering in the thousands, or competing in Triathlons, I plan on spending time with our Wounded Soldiers from the war. In short, my experiences have gone beyond the impossible. This year my goal is to be the first person to come back from a Brain Injury as severe as mine and complete the Ironman in Hawaii.

To find out more about Saul's story check out : = my foundation

What advice do you have for someone who has suffered an injury taking them of the bike a while in terms of building back up stamina & strength?

Take time and do not panic to get back into good form. Good condition is not something you can rush. I find that it is best to accept the condition you are in and use that to learn about yourself and improve as a person.

Where are you currently in your training for the Ironman

Georgia and Philadelphia

What sort of diet did you have which helped you recover?

I do not think my Diet helped in my recovery. I was 125lbs after my coma and I gained 50lbs in the hospital. My resting metabolic rate they calculated at 13,000 calories a day because of high temperatures and my brain trying to heal it's self. . I was eating 3 times a day put snack in-between.

What do you like about what Lance has done for the sport. Is there anything you would do differently that you are comfortable to say?

He has given millions of people hope. His comeback from cancer is inspiring and shows others that you can over come obstacles in life no matter how big they are. The only thing I would have done different is won the Tour de France on a French team.

Do you feel the sport has cleaned up the way it should?

It is getting better. Because of the longitudinal testing of the French riders and blood passports where they look for changes in blood chemistry it is impossible to take performance enhancing drugs in the sport. As a spectator you can rest assured that in the Tour de France is 100% clean and guys that try to cheat will get caught.

What is your view of North American bike racing today?

Cycling is growing and I hope is going to continue to grow.

What do you eat and drink while racing during event?

Gu H20, Gu Roctane gel(best gel in the market), GU Chomps Energy Chews
What is your back strengthening regimen?

Sit-ups, push-ups, very light weights.

How are you getting the message out on our Vets from Iraq.

As far a our vets. The deal is this is the first war were we are able to save the lives
of our VETS from injuries in all previous wars would have killed them. Because of this
it is creating tens of thousands of them with TBI and other disabilities that they
will take with them their whole lives. The disabilities are so sever the government is
over whelmed and is doing every thing in its power to get them the care they need.
The thing is that the Government is trying to build state of the art brain injury rehab centers
but there are not really in place much less can handle the needs of the thousands already with
brain injuries. It is sad to say that it has taken this war to get the governments attention on how
sever a brain injury it. As far as the American public, they pick up my book and
read the book jacket about a kid who came back from a life treating brain injury. But yet
they do not know how substantial that it. I believe it will be five years after the war when it
hits America how severe a brain injury is and the devastation we have done. This war will affect the lives of hundreds
of thousands of people. I am in a state of panic trying to raise awareness for brain injury and our wounded

Saturday, May 16, 2009

Knee Pain and Cycling

You ride your bike and and expect your knees to hold up - until they don't.

Knee pain for cyclists, previous injury notwithstanding, is usually not an isolated event; it is a process. We lose our health, knee joint included, one sand at a time until the point where we begin to notice it and do something to try and change the downward trajectory. Knee pain has truncated training rides, spoiled centuries and even ended cycling careers. But it doesn't have to - learn how to diagnose and prevent knee pain to keep cycling a part of your life for years to come.

What types of knee pain are common to cyclists?
Anterior knee pain which includes patellofemoral (also known as chondromalacia) is the most frequent type. Patellofemoral stress syndrome is an overuse injury that involves cartilage breakdown underneath the kneecap. Have you ever wondered why your knee makes crunching or popping noises going up or down steps? Often times this is a symptom of patellofemoral stress syndrome, because of an imbalance occurring above or below the knee. Some of this imbalance is caused by posture on the bike. Cycling positioning involves hunching forward and flexing your hips while in the saddle for long periods. If you are not fit to the bike properly this can exacerbate the problem. Other factors are muscle development distribution or a muscle strength deficit which can throw things off.

What causes knee pain in cyclists?
The knee can be affected by weakness of the gluteal external rotators which can lead to increased internal rotation of the leg and increase patellofemoral stress due to altered bony alignment. Cyclists typically have more developed calf and quadricep muscles than the average person. The vastus medialis is the tear drop shaped muscle that bulges out just above the inside of the knee and is usually well developed in cyclists, but if you have let riding go for a while or are new to the sport you can strengthen it with straight leg raises, lunges and dips or step downs with one leg going lower than the other while the other leg is on a block or stair. Other problems include muscle imbalances, excess motion in one or more joints, and leg length discrepancies. As we age a phenomena called cross linking occurs. This results in our tendons and ligaments being less flexible making them more susceptible to injury. Massage yoga and proper stretching can help minimize this. The body has a memory regarding injuries and sometimes it takes only a little more stress to setup for another injury episode.

Solution 1: Cycling Orthotics
A cycling orthotic can be made to compensate for problems that stem from too much motion occurring at the foot pedal junction.Not only can an orthotic decrease injuries but it can improve performance. This is accomplished by filling the dead space between your arch and the insole of your shoe so that energy is transferred directly to your pedal and not lost inside the cleat. An example of an imbalance which may be corrected is building lift on one side of an orthotic if there is leg length discrepancy. As a general rule, I usually compensate for half the difference of the discrepancy. Larger differences have to be adjusted in the crank arms or with shims. Another problem that can be addressed is excess motion, which can cause knee or arch pain. By placing a cant into a prescription for an orthotic, this force can be decreased. In cases where there are only minor issues over the counter insoles can sometimes be used.

Solution 2: Professional Bike Fitting
Bike fit issues and pedal selection may be the primary source or exacerbate existing knee problems. A saddle that is too high can lead to stress on the ITB, and patellofemoral loading can occur. If it is too low stress on the patella or quadriceps tendon can occur. If the seat is pitched too far forward stress on the anterior knee occurs because of too much flexion. If the saddle is too far back the ITB can be stretched because of the increased length. If the inside of your knee is bothering you and your clipless pedals have too little or no float, consider changing to a pedal with more float. If initial measures do not solve your problem a professional bike fit is in order. With this many moving - and connected - pieces, getting a professional opinion can not only increase your comfort and power, but also help ensure you can hammer for years to come.

Solution 3: Avoid the need for a Solution in the first place
Finally, try to control what you can. Keeping the knee warm in cooler weather is critical if you have any knee stiffness. Consider joining a yoga class or check out some yoga DVD's. Some people swear by glucosamine supplements to mininmize cartillage breakdown. Make sure you have no allergies to any of the components before you try glucosamine. If you have chronic swelling after exercise this may be a sign of more specific damage such as a meniscus defect or tear or internal ligament damage and a visit with your friendly neighborhood orthopedist is advised.

Remember that knee health is a process, not an event. Maintain your body more care than you put into your bike, because you probably use it more frequently and replacement parts aren't as easy to come by.

Saturday, March 28, 2009

Diagnostic ultrasound is becoming an immediate way to evaluate injuries without having to be scheduled for an MRI in many cases

Saturday, March 14, 2009

Yoga for Cyclists

Cycling next to swimming, is one of the least damaging high
aerobic sports. Nevertheless, there are a few chronic injury syndromes that can occur while riding. Many of these problems can be avoided if you warm up properly and take a few minutes after you ride with an appropriate stretching regimen. This is critical if you are undergoing a fast-paced workout or hammering the hills.

The reason you warm up is to get blood moving to your extremities so that they can contract more efficiently. The muscles I recommend that cyclists stretch include the calves (gastrocnemius), the front upper leg muscles (quadriceps), the back upper leg muscles (hamstrings), and outer hip muscles (tensor fascia latae) and core work.

There are many cycling, running and fitness books and websites that have excellent diagrams of the proper stretches. Remember that some info may be dated and that dynamic stretching is currently supported by research. Gone are the days of holding a stretch for 20 seconds. The progressions today are focused on gaining stability as well as on stretching. Stretching after a workout is important because of the shortening, which occurs after a muscle has been vigorously contracted in physical activity. An even better solution is to take a yoga class.

Think of your core as the linchpin that is necessary for muscles to work efficiently that are rotating around it. When it is weak you will feel it particularly in your back and hamstrings. Boat pose (Paripurna Navasana) with extension and flexion of your legs is helpful along with Superman or Locust pose (Salambhasana)with opposite leg and arm extended. You can create sequences that will also help protect your knees such as going from chair pose to warrior 3 . Hip openers such as squatting with feet flat are great hip openers after the compression that occurs on long bike rides. Different sequences to stretch the illiotibial band such as making a figure 4 with your legs while on your back are essential.

Muscle imbalances are a potential problem area that can plague your cycling. This happens commonly with the bigger front thigh muscles (quadriceps) overpowering the hamstrings or the calf muscles overpowering the front muscles in the lower leg. A muscle strength and flexibility evaluation can identify these problems. Consult a sports medicine specialist if these initial steps do not resolve your discomfort.

Tuesday, March 10, 2009

Barefoot Running

Mention barefoot runners and most people's first association is probably the legendary 1960 Rome marathon victory by Abebe Bikilla. To some advocates the conversation can get heated up quickly as if you were talking about politics. The fundamental question that has yet to be fully answered is whether one can accurately track a population of runners who are barefoot vs.shod.

Abebe Bikilla : Barefoot Icon
The story goes that Adidas who was the shoe sponsor for the games did not have any shoes that fit Bikilla by the time he trried on the shoes that were left. Bikilla decided to run the race barefoot as he had trained and won. Of his race he is quoted as saying that “I wanted the world to know that my country, Ethiopia, has always won with determination and heroism." . He did not repeat a barefoot run in 1964 in Tokyo. Part of this decision was attributed to the more industrialized roads in Tokyo. He also was recovering from an appendectomy 40 days prior and still managed to pull off a world record running this time in a pair of Asics.

Barefoot Running from the Savanna to the Track

Anthropologists such as Daniel Lieberman believe that the human foot developed to run barefoot. His hypothesis is that we were built for endurance running. He is doing a study with Vibram Shoes and is currently looking for barefoot runners. Prospective studies and randomized controlled trials of barefoot and shod running are difficult to achieve for obvious reasons. Robbins and Gouw argued that plantar sensation induces a plantar surface protective response whereby runners alter their behavior to reduce shock. The less-cushioned shoe permitted increases in plantar discomfort,a phenomenon that they termed "shock setting" Coaches such as Brooks Johnson and Vin Lananna have used barefoot running as part of an overall program to train the body to run long distances fast. In their opinion, to run properly, the foot needed to grasp and release on a variety of surfaces such as dirt, grass, road, concrete, and gravel.

The Shoe Industry Steps In

Several companies have weighed in with their versions of a running shoe which simulates barefoot running. Adidas approach was to try and copy the shape of the foot. In theory this will produce smaller lever arms which can react faster.The idea for the Nike Free was born out of a visit by a couple researchers to Stanford where Lananna was having athletes running barefoot as part of their training regimen. Many competitive runners I spoke to use barefoot running or shoes like the Nike Free as part of their training. Nike had students test it for 6 months and those using the the Free for 6 months had greater flexibility and strength in the foot. I interviewed Tobie Hatfield from Nike's Innovation Kitchen and Jeff Pisciotta from the Nike Sports Research Lab to find out how the shoe industry has incorporated the concept of barefoot training into their shoe design. They seem to be spearheading the shift back to their spirited roots to the old Bill Bauerman days when they made prototype soles on waffle irons. They studied 20 competitive runners on grass and kinematics analysis demonstrated a general trend towards full foot contact. If you watch the footage of Abebe Bikilla's Rome Marathon you will notice the same thing. The perception of some of the runners tested was that they were landing more towards the forefoot than they actually were. . Many believe that racing barefoot is difficult unless you have been running without shoes all your life. Many recreational runners are also starting to try barefoot running in an effort to prevent injuries and improve technique. The problem with this is that some of them will not have the conditioning to handle the transition to barefoot running. Experts in the field agree that any transition to barefoot running be done slowly.

The running shoe industry has built much of its platform on cushioning. In studies by Benno Nigg ,very soft shoes will bottom out when loaded, producing higher impact forces than firmer shoes that do not bottom out. Yet for any of us who have run downhill on concrete the more cushioned shoes seem to be less jarring so how do we reconcile this? I interviewed Benno Nigg, one of the foremost biomechanics gurus on running shoes and he was able to provide a new paradigm which he has published on. He started by telling me that there is no article in the literature which supports the notion that peak force transmission will be altered with varied levels of cushioning. In fact peak force transmission does not occur during heel contact as we might intuit but in midstance where the internal forces in joints muscles and tendons are 4 to 5 times greater than during impact There is something else that accounts for the perception that we are more comfortable in a certain level of cushioning. That something else is explained in Benno' Nigg's vibration model. When we impact the ground our soft tissue compartments (e.g. calf, hamstrings etc.) start to vibrate. However the human body does not like vibrations. Consequently, muscles are activated to dampen these vibrations. The degree of dampening that occurs in various types of shoes is what leads to our perception of comfort in the shoe. So we have an innate sense of what works for our bodies that is probably more accurate than any test could demonstrate for us. We must also consider the fatigue that occurs within the muscles that are working to distribute the vibrations. We know from other studies that fatigue can lead to injuries and this may be part of the answer we seek.

For runners such as Dave Watts,the director of the American Running Association things have come full circle. He relates that some of the early Tiger shoes he ran in in the 70's were not very beefed up in terms of cushioning. They resembled the more fashionable running shoes you see in boutiques in Brooklyn and West Hollywood. At one point he was running in orthotics prescribed for plantar fasciitis and a conventional running shoe. Now he gravitates towards shoes like the Free. The trend in the shoe industry seems to be toward offering more shoes with more minimalist designs. Keep in mind that for most runners barefoot training is good to train the small muscles that are not trained in stable running shoes.

It is hard to isolate all the force vectors because of the complex arrangement of the joints of the lower extremity. Robbins association between injury and wearing shoes has the possibility that wearing shoes increases the risk of injury, but other explanations are possible; for example, in developing countries barefoot runners may be too poor to seek medical attention, shod runners may wear shoes because they have problems running barefoot.

There appears to be a continuum of preference for barefoot running related to a runner's efficiency and abilities. Certainly runners that have grown up running barefoot in areas where it is more prevalent, like Kenya, have been conditioned to run more efficiently barefoot than more industrialized countries. Beyond that elite athletes are exceptional in their foot musculature and would have an easier time in general running barefoot than others.

A word about zealots on both sides of running barefoot vs shod. Some will experience cognitive dissonance when their point of view is challenged. This means that when presented with evidence contrary to their point of view they will tend to deny it or reframe the evidence as if it was part of their argument all along. We should remember this, otherwise we are no better than the iconic Dr. Zaius who held both the posts of both minister of science and defender of the faith, a conflict of interest that does not seek out answers, only support for our own preconceived views. It turns out for the answers are very individual and may not be what we expect.

Judah Tim, Bikila: Ethiopia's Barefoot Olympian
Barry Block DPM personal communication
Tobie Hatfield Jeff Pisciotta,personal communication
Benno Nigg Phd personal communication citations
Nigg, B. M. and Wakeling, J. M. Impact forces and muscle tuning - a new paradigm ESSR Exercise and Sport Sciences Review (29) 1 37-41, 2001
Nigg, Benno New Ideas and Concepts in sport shoe development
(Robbins and Hanna, 1987). ,
Robbins SE, Hanna AM (1987). Running-related injury prevention through barefoot adaptations. Medicine and Science in Sports and Exercise 19, 148-156
Robbins SE, Gouw GJ (1990). Athletic footwear and chronic overloading: a brief review. Sports Medicine 9, 76-85

Monday, March 2, 2009

Hot Foot

This is a post by my PT colleague Steve Berkey & Kerri Kramer.
He's developing a cycling clinic in Fredricksburg, VA.

Let’s be honest. Endurance athletes get some twisted satisfaction from
pushing their bodies to the limit. They - or dare I say we - spend hours
demanding more of our bodies so that we can experience the adrenaline
rush crossing yet another finish line that previously seemed unattainable.
We beat ourselves up, and during training in pursuit of the next great race,
aches and pains inevitably arise. After a while, it’s easy to forget what
“normal” workout symptoms are. Some clues: Numbness, tingling, and
burning sensations do not fall within the realm of expected pains, nor are
they safe to ignore. Swimming, biking, and running each have the
potential to wreak neurological havoc on specific regions of the body, but
in this article we will focus on an injury specific to cycling.
In the front of the line, waiting to inflict misery on the long-distance
cyclist, is the infamous “Hot Foot.” Some of you are already well-acquainted
with shooting pain under the ball of the foot, numbness and tingling in the toes,
and that debilitating sensation that someone is pointing a blowtorch at the
bottom of your foot. These unpleasant symptoms, known as metatarsalgia
in the medical world, are typically caused by compression of the interdigital
plantar nerves that run between the bones of the feet (metatarsal heads).
Inflammation of the capsules or bursae at the toe joints, as well as inflamma-
tion of the bones themselves, can place pressure on the nerves of the feet.
It sounds like these inflicted cyclists are in for nothing but trouble. But
wait! It’s not time to hang it up and retire yet. Localized metatarsalgia can
usually be solved with a simple modification to the shoe, pedal, or both. The
trick is to identify the specific cause and address it.
Put the Puzzle Together
Treating “hot foot” is much like solving
a puzzle. The problem most often exists
in the interface between the foot and
the pedal. By following the systematic
process below, “hot foot” can become a
problem of the past.
1. Loosen the shoes: The delicate nerves
and vessels of the forefoot can become
irritated when compressed. By loosen-
ing the straps on the shoes, the nerves
and vessels have room to “breathe.” It
is not uncommon for the foot to swell
after riding longer distances; therefore it
is very important loosen the shoes. For those who prefer the feel of tighter,
more secured straps, another option is to loosen them just during the rest
2. Try thinner socks: Another method to increase the space within the shoe
is to wear thinner socks. Experiment with different cycling-specific socks
to alleviate pressure.
3. Adjust the cleat position for clipless pedals: Clipless pedals are great
and a necessity when cycling competitively. They maximize power, but can
also contribute to increased pressure under the forefoot. This can create
“hot foot” for certain types of foot anatomy. Most bicycle fit techniques
recommend positioning the cleat so that the knuckle of the big toe (the
first metatarsalphalangeal joint) lines up with the pedal axle (Figure 1).
Unfortunately, this is not always appropriate.
A simple method to reduce the pressure under the delicate nerves and ves-
sels is to move the cleat back towards the heel of the shoe, approximately
two millimeters. If this doesn’t change the symptoms, move the cleat closer
to the heel, as far back as possible. If you notice any knee pain after this
adjustment, consider a professional bicycle fit. Remember that, if the ad-
justment is large enough, other aspects of the bicycle fit may be affected.
4. Consider specific insoles: Gait patterns differ from person to person.
One pattern is overpronation, or walking more on the inside of the foot.
This movement dysfunction will cause a functional increase of compression
within the shoe while cycling. Using cycling insoles made by Specialized,
Superfeet, and Your Sole can provide additional support and may help al-
leviate “hot foot.”
More info about Steve on

Sunday, February 15, 2009

Lost in Space

Recent research has now confirmed how we process are movements. We have two ways we measure where we are in space without thinking about it. The first way is with something called plate cells. Plate cell are neuron's connected to the hippocampus. If you are in your kitchen and you are navigating to the refrigerator in the dark you are activating the plate cells, Grid cells help place where your body is regardless of context.The cells allow you to triangulate where you are in space.

The ability to tap into practiced movement patterns works a little
differently. While we are learning the movement we are using the conscious
part of the brain known as the I-function. Once we have learned the movement pattern we can access the practiced movements and go on auto pilot. The I-function does not have to be burdened. When we have learned a movement sequence it becomes more difficult to consciously think about the movements versus just doing it. Imagine thinking about each key stroke while you were playing the piano or thinking about
what your arms, torso and feet are doing playing golf or jumping a 360 off a ski jump. Much of coaching performance revolves around not over thinking movements. For some
unbelievable feats of agility copy the following link:

We use this knowledge to retrain our body after injury. A good example is
how we rehab after an ankle sprain. A wobble board stimulates the
vestibular cortex. People adapt quickly. This helps recalibrate your ankle balance after an injury. Diabetes can cause nerve damage that alters the feedback loop with propioception.

Saturday, February 14, 2009

My Sports Medicine Blog

I've been a board-certified podiatrist since 1992. I ran track and cross country in high school followed by a short-lived track stint at Indiana University as a walk-on. When I injured my achilles tendon, I switched over to bike racing and tried my hand at IU's Little 500 Bike Race popularized in the 1970's hit movie "Breaking Away."

Years later, I tore my ACL playing soccer just before turning 40. I realized that I would need to take my conditioning much more seriously to avoid further injuries. So I sought out the best rehab protocols and programs out there today. Now I do my best to integrate everything I've learned into my state-of-the-art sports-medicine practice. I try to maintain an active lifestyle: a decade as a snow-ski instructor, road biking, conditioning, and yoga, all of which has allowed me to stay injury free for the past eight years. Part of the key to remaining healthy is to incorporate your workouts into your daily life whether it be your commute to work or at home.

I'll be sharing knowledge from my medical practice and my experience with athletes, information that will be useful for both the weekend warrior and more serious athlete: for training and living injury free. Stayed tuned in for special guests--friends and athletes with their own stories to tell. I welcome your feedback.

Wednesday, February 11, 2009

Floyd Landis & Santanna Moss Put Steroids Back in the News "Spin, Wash & Repeat"

Floyd Landis & Santanna Moss put Steroids Back in the news "Spin ,Wash & Repeat "

With Floyd Landis's new allegations impicating Lance Armstrong and other big guns a la Jose Canseco plus Santanna Moss's HGH link allegation here is a the low down on the differences between all the acronyms EPO, HGH, & steroids. If the charges stick aging vets like TO may get a second shot for playing time.

The Legacy of Steroids

Do you remember the night before the big fight in Rocky where he visits the Spectrum only to find that the banner of him has the colors on his boxing trunks reversed. The promoter who happens to be there that night responds to Rocky's soft protest with "It doesn't really matter, Rocky, does it. I'm sure you'll put on a good show." The show has taken over pro sports and our
cultures obsession with being the best at any cost is overshadowing the athletes who are training hard a la old school

In 1935 Koch was able to isolate 20 mg of steroid material from 40 pounds of bovine testicles from the Chicago stockyards. In 1935 the first testosterone was synthesized from cholesterol by a scientist named Budenant of Schering. 1 week later Ruzicka working under Ciba announced a patent for the synthesis of testosterone and the two scientists working independently shared the Nobel prize in chemistry.
Between 1948-1954 Ciba and Searl sythesized many analogues of testosterone. In 1954 at the weightlifting world championships, after being invited out to a bar the Soviet team doctor confided in the US team doctor John Ziegler that his team was using testosterone. Ziegler began using them for his team and later began working with Ciba to synthesize diabanol (methandosterone).

The IOC banned the use of Steroids in 1967. Prior to the ban the Germans used and researched steroids extensively. In 1972 the IOC began a full testing program for detecting steroids.

The anabolic steroid act of 1990 made steroids a schedule III drug along with morphine and amphetamines. It is illegal to use schedule III drugs without a doctor's prescription. The sale of steroids on internet is governed by the point of purchase. There are some jurisdictions where the sale of steroids is permitted without a prescription. It is not uncommon for websites to sell steroids and offer advice about how to mask detecting them.

Who is using Steroids in the US?

The Mayo Clinic estimates that 10% of the anabolic steroid users are teens which accounts for about 300,000 . A survey of 12th graders in 2000 showed 2.5% had used steroids while in 2004 the number climbed to 3.4% One survey found that 6.9 % of football players in Indiana had used steroids. Surprisingly, the main motivation for kids as reported by several studies was not scoring touchdowns but looking buff, one of our country's other national obsessions. Another misconception is that children emulate their sports heroes behavior. According to a Sports Illustrated poll 99% of the respondents that they would not use steroids because pro athletes use them. A study in Pediatrics showed that 65 % of teens would consider using steroids if they thought it would make them reach their athletic goals even if they might cause them harm. 57% said they would even if it meant shortening their life.

On the Bubble

Some athletes lose their chance to compete because others are cheating. The pressures to perform begin at an earlier level than ever, just ask any travel league athlete. As sports become more institutional the pressures to perform increase. Parents can add pressure and sometimes provide financial backing for steroids. Some athletes feel compelled to cheat to survive the last cut or to go from bench warmer to starter.

Remember that anabolic steroids build up muscle tissue but pose unique medical risks for children. They can stop the production of testosterone, which will inhibit skeletal growth in teens. There is increased risk of knee and ankle injuries because the ligaments may not be able to withstand the forces generated by the larger steroid enhanced muscles. Also because the kids taking steroids are bigger, stronger and faster there is a greater chance of injuring other player in contact sports. A largely overlooked risk in the mainstream media is that because much of steroid traffic is underground, there is a greater likelihood that the steroids used will be at or below veterinary grade making them more dangerous. The internet appears to be the pharmacy of choice for teens and is widely used for illegal purchase despite the postal sevice’s efforts to crackdown on illegal shipments. Steroids use is linked with a higher early death rate. In a study reported by the National institute of Drug Abuse mice given steroids at levels proportionate to athletes for 1/5 of their lifespan experienced a higher early death rate.

Other Medical Risks

It is important to note that there are important differences within the class of anabolic steroids. The oral 17 alpha forms are the most dangerous. The differences arise because this form of alkylation was developed expressly to allow oral steroids to have significant effects, meaning they will withstand a first pass through the liver thus increasing the liver’s exposure. There is evidence that long-term use of anabolic steroids in the oral form may damage the liver including necrosis of the liver. The injectable form has minimal exposure within the liver. Steroid use can also lead to lower HDL cholesterol and increased LDL levels and triglycerides. The data is scant for a direct causal relationship between cardiovascular disease and steroid use but cohort series suggest a link. Steroids impair glucose tolerance and increase insulin, a state that mimics type 2 diabetes.

What About Roid Rage?

Research on mood swings is still being reported but there are some important statistics. It is estimated by medical experts that 1-2% of steroid users will experience some extreme form of behavior. 3 of 4 studies documented some irritability with steroids giving scientists the hypothesis that some but not all steroids may cause mood changes. One study using testosterone vs. placebo found increased aggressive behavior in the placebo group leading the investigators to the conclusion that a placebo effect may be responsible for these behaviors. Within the individuals variability was noted suggesting a wide range of steroid affects on mood. Anabolic steroid can create withdrawal symptoms when suddenly stopped. This may lead to violent episodes. In addition, sudden cessation of steroids can lead to increased intracranial pressure that can be life threatening. 9.3 % of drug abusers in a drug recovery program reported previous use of anabolic steroids. Many feel this secondary drug use is due to insomnia and irritability associated with steroids.

Signs of Steroid Use

One of the main points that most people do not realize is that because of the masculine changes steroids cause, the upper body muscle development distribution is greater than the lower body. Deepening of the voice, breast reduction, and body hair growth are changes noted in women. Testicular atrophy and development of breasts are changes that can happen to men.

Other Performance Enhancing Drugs

Human growth hormone is another agent that is used to increase lean muscle mass an increase bone density. Like steroids they are banned in sports. Popularity of HGH increased after a 1990 New England Journal of medicine article in which there
was some misinterpretation of the conclusions leading some to view HGH as an anti-aging elixir. The performance benefits if any and side effects are not nearly as dramatic. In theory it can increase the chance of developing diabetes. There is a legal homeopathic inhalent version of HGH which is available. EPO is a genetically engineered version of a natural hormone produced by the kidneys that increases bone marrow activity to make more red blood cells. Dangers of EPO use include heart attack and stroke. Over the counter supplements like creatine canbe harmful and are banned by the NCAA and the Olympics and NFL. Creatine can cause cramping and diarrhea and has been linked to muscle injury and kidney problems.

The Problems with Testing

Although testing has gotten better many feel that the testing can’t keep up with the cheaters. WADA has a budget of about 24 million but it is hard to keep pace with the designer steroids that some elite athletes use to evade detection. That’s the opinion of experts like Dr. Charles Yesalis and Don Catlin who runs a company called Anti-Doping research. Some drugs like epo are hard to test directly and use an indirect test of a hematocrit above 50% before confirmatory testing. One group of high schools randomly tested 500 athletes to yield 1 positive steroid result. At $175 per test a more cost effective way of prevention may be an emphasis on education.

Education on steroid use is largely regulated to posters in wrestling rooms etc. with no formal curriculum. Given the rise in use by teenagers it would make sense to offer some steroid awareness curriculum before major competitive high school sports programs. Steroid awareness can also be raised in local community athletic programs. Positive adult role models can help.

Above and beyond the health risks what kind of message are we sending our children when we have many parents putting pressure on their children for achievement and institutions that have been so slow to embrace a steroid free culture ? It’s ok to cheat as long as you don't get caught? Gary Hall Jr., Olympic gold medal winner in the 50-meter freestyle may have summarized it best when he said that we live in a society where we are innocent until proven guilty-the key word being ‘proven’. We don’t have any way of proving people are cheating.” He points out that many athletes have been implicated in steroid use by scandals such as Balco rather than through testing with the World Anti-Doping Agency (because of the difficulty in getting positive steroid tests.) Bill Moyers wrote that when we give up the fight to ensure an equal playing field we have given up on the bedrock of democracy itself. Athletes and others using steroids is really a reflection of our society rather than a problem unto itself.

Thursday, January 22, 2009

Less is More, More or Less

Much of our decision making process in based on our perception of reality. We may have a “gut” feeling about something one way or the other but what exactly causes this? Gerd Gigerenzer describes simple rules of thumb which become the basis for our decisions . The rules of thumb ignore other information. For example, we have a recognition rule of thumb or heuristic that enables us to process something familiar to us very quickly. Studies have shown that many times keying in on a couple of the most important variables is a much more valuable predictor of a future outcome than many weighted variables. The art is knowing which information to ignore.
An example is an ingenious study design in which used a very sophisticated set of computer generated variables to try and predict which Chicago schools would have the highest rate of dropouts. The data from the first half a of schools were used as a predictor for the second set of schools. It turned out that asking two questions fared better as a predictor of the future “What was the attendance rate” and if that was more or less the same moving on to the next question which was “what were the test scores”.
The healthcare arena has many examples. One of the most compelling was some research done at the University of Michigan on coronary care. It was found that predicting heart attacks as a basis for ICU admission was no better than chance. Much of this was attributed to the spector of malpractice ans so called “defensive medicine”.This meant that you had a 50/50 chance of being placed erroneously in the ICU with the associated risks of infection etc. It was discovered that too much emphasis was place on medical history questions such as a history of diabetes or hypertension. After constructing a very elaborate logistical regression instrument results improved as expected. Many of the doctors did not like using this method because they found the charts cumbersome. When the instrument was taken away surprisingly doctors were able to predict about as well because they were armed with a better internal algorithm for making a choice after being exposed to the more complex instrument.
It turned out that the most important question was whether or not there were ST segment changes on the EKG and if so the ICU was statistically the right choice.. The next most important question was whether the admission complaint was chest pain and if not a regular nursing unit bed was more appropriate.

Monday, January 19, 2009


Sunday, January 18, 2009

Fatigue and Injury

We all know the effects of individual muscle fatigue on injuries, your leg muscles get tired and all of a sudden you injure your knee. EMG studies have shown that the anterior shin muscles fire 85 % over their fatigue threshold in running. Hence it is no surprise that many runners develop shin splints. It turns out that over all fatigue plays an important role just as localized muscular failure to an area. No one has been able to prove decisively why this happens but it is probably multifactorial. As our
form degrades with fatigue we are in a less stable position to prevent injury. It is also reasonable to assume that as you fatigue the brain's ability to execute precise movement patterns also degrades. What to do? Develop the core and support muscles. Heighten the body's spatial awareness with agility drills. This is why track work deconstructs the running stride and uses drills to help perform more efficiently.

Lost In Space

Recent research has now confirmed how we process are movements. We have two ways we measure where we are in space without thinking about it. The first way is with something called plate cells. Plate cell are neuron's connected to the hippocampus. If you are in your kitchen and you are navigating to the refrigerator in the dark you are activating the plate cells, Grid cells help place where your body is regardless of context.The cells allow you to triangulate where you are in space.

The ability to tap into practiced movement patterns works a little differently. While we are learning the movement we are using the conscious part of the brain known as the I-function. Once we have learned the movement pattern we can access the practiced
movements and go on auto pilot. The I-function does not have to be burdened. When
we have learned a movement sequence it becomes more difficult to consciously think
about the movements versus just doing it. Imagine thinking about each key stroke while you were playing the piano. Much of coaching performance revolves around not over thinking movements.

We use this knowledge to retrain our body after injury. A good example is how we rehab
after an ankle sprain. A wobble board stimulates the vestibular cortex. People adapt quickly. This helps recalibrate your ankle balance after an injury.

Friday, January 16, 2009

Resistance (Strength) Training for Cyclists

This submission is from Dr. Paul Glodzik:

I decided that this would be a good topic to cover since I recently attended a very good seminar on Olympic lifting. I also just started to interact with some fairly high- level racing cyclists. One of them asked me how resistance training could benefit a cyclist. I had to stop and think because there are multiple answers, which led me to write this article. I need to explain some concepts that the average cyclist or person in general doesn’t know or correctly understand about resistance training. It is unfortunate that most people think about resistance training and someone like Arnold Schwarzenegger immediately comes to mind. There are many styles of resistance training that have completely different effects on the body than bodybuilding, the method Arnold used. Never mind the large doses of steroids he did as well. Bodybuilders are interested in increasing the size of their muscles without any regard for function. The increase in muscle size and mass is a concept known as hypertrophy. Most cyclists know that this extra size and weight is not advantageous when on their bike. Fortunately, there are other ways to resistance train and get stronger with little to no hypertrophy.
The types of resistance training that can be used by cyclists can be broken into three major categories - endurance, strength, and power. Of these the easiest to explain is endurance training. By endurance I am speaking of muscular endurance. This is something most cyclists have experience with. Muscular endurance can be increased in many ways. You can cycle for long time periods at lower energy outputs, run distances, perform aerobics, or resistance train using lighter weights with higher repetitions. If you are training for a century ride with the goal of only finishing this is the type of training you need to perform the most. That doesn’t mean you should neglect the other types of resistance training, however.
To understand strength training you need to know the definition of strength. Strength is the ability to exert a force against an object. When you are trying to increase your strength the object is to be able to produce more force. This can be accomplished in different ways in the body. Increasing the cross sectional size of the muscle (hypertrophy) is one way. However that is not what a cyclist wants. You can increase the amount of muscle fibers recruited within a muscle to make that muscle more efficient and you can increase synchronization of muscles that work together. Exercises such as squats, dead lifts or pull-ups are examples of this type of exercise. When performing exercises for strength you should work yourself up to a point where you are using very heavy weights but with only a few repetitions. By doing so you will minimize the hypertrophy but still increase your strength. One example of the effects of strength training would be the effects on your quadriceps. By performing strength exercises a cyclist will have more efficient quadriceps muscles that can keep a consistent pedal rate over a longer time. The muscle doesn’t need to recruit as many fibers to produce a certain force at first and then can recruit more fibers as fatigue begins to occur.
The final category is power training. To understand this, power needs to be defined as well. Power can simply be defined as follows: Power = Force x Rate. This means that a force is exerted on an object just like true strength training but there is a time component to it. Power exercises are also known as Olympic lifts because they are in the Olympics. The exercises that fall into this category are the clean and jerk and the snatch. These exercises are extremely explosive and they produce huge amounts of force over a very small time frame. Most cyclists would believe these exercises have no real benefit to them. I would have agreed until I went the seminar I mentioned earlier. There is research that proves that anaerobic exercise, which power exercises are, can actually increase aerobic capacity but not the other way around (Paavolainen). I wouldn’t advocate that cyclists start performing Olympic lifts without professional help, however. It is not say these exercises wouldn’t benefit a cyclist’s power output, but because they are very technical and hard to teach. There are power assistive exercises that can be used instead. Think of it this way - if you are in a race and suddenly someone jumps out of their saddle to try and break away, in many cases you want to be able to follow them. If you are 100 meters from a finish line, you may need to sprint. By performing power exercises, you would be able to increase your power output very quickly and be able to catch that rider or out-sprint the other riders.
A type of training that has become very popular, and in my opinion, most important, is core training. To truly tie together all of your training, you must train your core. Most core exercises are performed with the main goal of stabilizing joints, have fairly low force production, and can be held for long periods of time. A plank or side bridge is a good example of this type of exercise. Core exercises are usually performed with only your own body weight or a medicine ball. When you are riding for three or four hours in a row do you ever notice that your back starts to ache? There are many reasons for this, but a major one is that you are in a tucked position and your core muscles are not working to stabilize your spine. If you perform exercises to strengthen your core muscles, the increased stabilization will allow you to withstand the tucked position for longer periods of time on rides.
Now that I have explained the different types of resistance training, most people will want to know what exercises to do. That is a bit extensive for an article like this, but I can at least start you off in the right direction. To begin with, decide what you are attempting to gain from your resistance training. Are you looking to increase your leg strength, or decrease the effects of a long ride? Maybe you have been training using wattage and realize that you are not producing the output you would like so you want to increase your power. Once you have decided on what it is you are attempting to accomplish, you need to figure out how often, where, and with what equipment you are going to train. If you don’t have these questions answered you will never stay with your training program. I am not a fan of using machines to resistance train. When you are using a machine only one specific movement or muscle is being trained. Have you ever tried to ride by using your quadriceps only? It doesn’t work that way! By using free weights (dumbbells and barbells) you are training multiple muscles and also forcing yourself to stabilize joints. When you use a machine, stabilization is already done for you.
This is the point at which things become difficult because of the specificity of training for each person. Two riders may want to accomplish the same thing but are starting at totally different points in training. The easiest way to figure out what you should be doing is to know how much training you have had and how advanced you are with different exercises. If you have never touched a weight in your life, any basic exercise routine that works the major muscle groups will help. If you have trained for years and are proficient at many exercises, it may be time to find yourself a strength and conditioning coach. If you are looking for a trainer, your best bet is to talk to the other people you ride with or talk to the riders you would like to be more like about coaches (trainers) that they trust.
I feel I should discuss safety a little. Resistance training when performed properly has very little chance of injury (Stone). Having said that, you need to learn how to perform the exercises correctly and listen to your body. No one would get on a bike and ride 100 miles if they hadn’t trained for a while. The same concept applies to strength training. Don’t use weights that are too heavy and cause you to break technique. Remember that a good training regimen should always have rest periods or decreased training loads built into it. That way, over-training doesn’t occur.
If you have any questions feel free to contact

Paavolainen L, Häkkinen K, Hämäläinen I, Nummela A, Rusko H. “Explosive-strength training improves 5-km running time by improving running economy and muscle power.” J Appl Physiol. 1999 May;86(5):1527-33.

Stone, M., et al. "Injury Potential and Safety Aspects of Weightlifting Movements" Strength and Conditioning 16(3):15-21, 1994.