Ankylosing spondylitis is a common cause of chronic low back pain in young men. It usually occurs between the ages of 15 to 35, with an average age of 26-27 years old.

The disease involves a process of joint inflammation followed by joint erosion and then finally joint fusion. This series of events can occur over a period of 10 years but only a minority of patients end up with the most severe joint problems.

Approximately 1/3 of patients with this disease also have other systemic changes such as iritis (inflammation of the eye) and, heart, blood vessel, gastrointestinal and genitourinary problems.

2. What are the causes/predisposing factors of injury?

This inflammatory condition appears to be an autoimmune disorder.

3. What are the symptoms?

General symptoms include aching and stiffness felt in the lower back, buttocks and thighs that can change from side to side or be on both. Most of the symptoms are felt predominantly in the morning and evening hours. There may also be periods of complete remission of symptoms. Other locations where stiffness and aching may be found are in the hips, mid-back and shoulders. Chest expansion may be diminished in some instances where fusion of the mid-back joints has occurred. Sciatica may also occur, but does not go below the knee.

What can be done to prevent or treat this injury?

Diagnosis is the key. This condition must be differentiated from other causes of chronic low back pain, so that appropriate management can occur. To achieve this, x-rays and specific blood work (erythrocyte sedimentation rate and HLA-B27) should be performed.

Treatment consists of antiinflammatories, postural training, and therapeutic exercise to maintain joint mobility and proper posture.

1. What is it?

The piriformis muscle is situated deep in the gluteal area and goes from the front edge of the sacrum to the greater trochanter of the femur. This muscle acts to rotate the leg away from the body. Anatomically, the sciatic nerve runs under the piriformis muscle. If the piriformis muscle becomes spastic or tight, the sciatic nerve can be irritated, creating a piriformis syndrome.

2. What are the causes/predisposing factors of injury?

A twisting or pivoting injury on the affected leg can irritate the piriformis muscle. Also, sitting cross-legged, having a functionally short leg from either foot hyperpronation or a posteriorly rotated pelvis can cause a piriformis syndrome. The latter problem is due to the piriformis muscle being overstressed as it tries to stabilize a rotated and tilted sacrum.

3. What are the symptoms?

An intense deep ache may be felt in the buttock and even travel all the way down into the foot. Exquisite tenderness can be experienced when the piriformis muscle is palpated. Resisted external hip rotation (trying to push bent knees apart, feet together) will be weak and painful.

4. What can be done to prevent or treat this injury?

Foremost, make sure if you pronate too much, you have proper footwear and/or orthotics. Also, attend to any dysfunctional lumbar spine and pelvis biomechanics by a combination of spinal manipulation, stabilization and strengthening exercises.

Specific treatment consists of deep soft tissue treatment, manipulative therapy, therapeutic muscle stretches and strengthening of the hip muscles.

Tell Me Where it Hurts

One of the most frustrating issues both the patient and their healthcare provider must deal with is poor communication. On some occasions when I see a patient about an injury, they go on at length providing details that do not relate to the problem. Here, in brief, are the details that you should provide your healthcare provider with to help them solve your injury problems.

We use the letters OPQRST to shape the history taking part of an examination.

O = Onset. This is the what, when, where and how question. Did you have trauma or not? Did this start slowly or suddenly? Is this recent or an ongoing injury. This question relates to the possible mechanism of the injury. Try to be accurate in describing things such as is the injury one week or one year old.

P = Palliative and Provocative. What makes the injury feel better or worse? Be specific with these details.

Q = Quality. What does the injury feel like? (Dull, achy, sharp, tingling, burning or loss of strength) If you have problems relating to these descriptions, try relating it to things you are familiar with.

R = Radiation. Does the pain stay in one place or does it travel around. If the pain travels around, what does this pain feel like?

S = Severity. How much does it hurt? I use a scale of 0 to 10, where 0 is no pain and 10 is the most pain you could possibly feel. Does the pain vary in intensity?

T = Temporal. What is the timing of the pain? Is there a certain time of day or night that the problem seems better or worse? Is there a pattern?

Hopefully, if you can go to your care provider with all these details in hand, a more focused and effective visit will be the result. I have found that it is not the amount of time spent during the visit that matters, it is the quality of information obtained that most determines a successful outcome.

1. Layer your clothes. Try moisture wicking clothing – it really works. The newer technology fabrics allow perspiration to occur without getting trapped next to the body or on the inner lining of your outer shell. For the upper body, I prefer to go with a lighter inner layer, a medium thickness insulating second layer if it is really cold, followed by an outer shell. This gives me the option of unzipping or removing the outer layer if I get too warm. Winter tights, and if necessary an outer pant shell over top, should be adequate protection for the lower body.

2. Get shoes with a good grip. Check the soles of your running shoes: if they are relatively smooth, you will likely have traction issues. Alternatives are trail running shoes or specialized spikes that you can slip onto your shoes. I just use my regular training shoes (Saucony Grid Hurricane VII’s) since they have a pretty aggressive tread pattern.

3. Don’t forget your feet. Socks can be an overlooked item of clothing. There are many high tech socks out there that provide better insulation that may make your run more comfortable. If necessary, you can always wear 2 pairs, just remember to loosen your shoelaces to accommodate them.

4. Mittens are warmer than gloves. On really cold days wear running mittens so your fingers can share their warmth with each other. Gloves are more stylish, but give up more heat.

5. Cover your ears. Make sure that your ears have adequate protection from the cold. I have suffered from frostbite to my ears from winter running- it’s not pretty and very uncomfortable when it thaws out. Be sure that your hat (toque) covers your entire ear and is thick enough to provide adequate insulation. A good option is a balaclava or earmuffs.

6. Ever had your eyes freeze shut? In our winter climate, I’ve had this happen. Any tears produced can freeze, essentially gluing you eyelashes together with ice. The solution- apply petroleum jelly to your eyelashes and eyelid areas. Any tears simply slip away.

7. Finally some training tips. Start your runs into the wind and finish with the wind on your back. Try running at the warmest time of day. Do not run long or hard after fresh snowfall as this will likely lead to overuse injuries of the ankle, knee or hip. Wear reflective clothing if you are running when it is dark. Carry money for a bus or a cab with you. Try running routes where there are facilities available along the way to warm up or use the bathroom.

Have a Merry Christmas and a Happy and Healthy New Year!

Osteoarthritis describes a condition where the cartilage that covers the surface of our joints begins to deteriorate. This process tends to begin with small defects including cracking, fissuring and thinning and may end up with a bone on bone situation where the cartilage is completely destroyed.

What are the symptoms?

Osteoarthritis tends to involve weight-bearing joints such as the knee, hip and spine. Usually the symptoms consist of morning stiffness that loosens up after 15 to 30 minutes of activity. There may also be grating or crunching noises that come from the affected area. If the condition worsens, activity will aggravate the symptoms. There may also be mild swelling of the joint along with enlargement of the joint.

What are the causes/predisposing factors?

There are a number of theories as far as causation. One theory suggests that biomechanical faults place abnormal stresses on the joint which over time create damage. Another theory argues that chemical changes occur in the joint leading to joint damage. Personally, I feel that it is a combination of biomechanical and biochemical changes that prompt the development of osteoarthritis. Regardless, the net result is the same: the material that makes up the joint cartilage is compromised, which leads to a weakening and eventual breakdown.

What can you do to prevent or treat osteoarthritis?

Here’s where it gets interesting. There are literally hundreds of scientific investigations and about 20 well designed research studies that have demonstrated a substance called glucosamine sulfate can help prevent and treat osteoarthritis.

Glucosamine sulfate is naturally produced by our body, and is used to make a molecule called chondroitin sulfate, which is a component of joint cartilage. It is thought that as we age our body produces less glucosamine sulfate, which leads to a decrease in cartilage production. This is why supplementing with glucosamine sulfate may be a very smart strategy since you are providing the raw materials your body needs to produce cartilage.

Glucosamine sulfate supplementation should be approximately 1500mg per day, preferably divided into 500mg doses 3 times per day. This regimen should help maximize absorption.

Some people may wonder about supplementing with chondroitin sulfate. Unfortunately, chondroitin sulfate is very poorly absorbed (less than 15%) because of the large size of the molecule. Glucosamine sulfate being a much smaller molecule is more readily absorbed by the body (over 90%). So if you are trying to choose between them, glucosamine is the better choice.

The one possible downside of glucosamine sulfate supplementation is the time it takes to notice relief of the symptoms. This is because the supplement first must be taken up by the cartilage producing cells (called chondrocytes), then converted to chondroitin sulfate and then distributed into the joints.

What I recommend to speed up relief is to take some other natural products along with glucosamine sulfate that give it an added “kick”; specifically, MSM (methyl sulfonyl methane), bromelain and quercetin. These ingredients are natural antiinflammatories that provide quick relief of the symptoms of osteoarthritis while the glucosamine sulfate is being processed by the body. If you plan on taking these supplements make sure you are purchasing quality products that guarantee their purity and potency and should state as much on the label. Figure on spending about a dollar a day for a combination glucosamine/MSM/bromelain/quercetin supplement that is of good quality. If you think that is expensive, remember most people pay at least four times that amount per day on their coffee and lattes which may have an anti oxidant benefit, but doesn’t do much good for their joints. So, are you and your joints worth it?

One final word on glucosamine sulfate, if you are pregnant or breastfeeding, you should not take this supplement. The same holds true if you have kidney disease or kidney problems. When in doubt, consult a healthcare professional knowledgeable about nutritional supplements.

Other strategies for osteoarthritis include analgesics for pain (capsaicin cream 0.025% is a good one), non-steroidal antiinflammatories (which have many side effects, can speed up arthritic change if taken long term, and may cause heart problems), joint injections, and ultimately joint replacement.

Active treatment consists of joint mobilization and manipulation to normalize joint mechanics and strengthening and stabilization exercises for affected areas.

Remember, osteoarthritis needs to be actively managed for the best long-term results.

This has led to other studies that have shown that pre-activity stretching with resistance (weight) training led to a decline in peak strength during the activity. There is also evidence that indicates that stretching without a proper warm-up can actually cause injuries. So are we supposed to stop stretching?

The short answer is no. Stretching if done properly should be part of your overall training regimen, and is an essential part of a rehabilitation program if you are recovering from an injury. Ideally, you should do light activity such as a jog to warm up the body prior to stretching. Cooling down is the same, do a light jog then finish with the stretches. When doing stretches be sure you don’t bounce because you can injure the muscle by overstretching. Try holding a stretch just short of the point of discomfort for 10 to 60 seconds, relax and repeat 3 times.

For injury rehabilitation, stretching is vital to restore range of motion, break up scar tissue and adhesions that form as a normal part of the healing process, and helps in the neurological retraining of movement patterns by stimulating joint receptors.

As for research- maybe the benefits of stretching are an answer in search of the right question.

Frequency refers to the number of training sessions per week. As the frequency increases, so does your risk for musculoskeletal injury if you do not have adequate conditioning.

Intensity refers to the exertion level of a given workout. Higher intensity training creates stress that we want the body to adapt to which results in improved cardiovascular and muscular efficiency. For runners this means the ability to run longer, faster or both.

Time is simply how long your workouts are, usually measured in minutes.

Recovery is the rest taken between workouts, and is essential since it allows the body to rebuild and repair itself between workouts.

The factors of frequency, time and recovery are quite easy to monitor and control. Intensity is not readily measurable.

For most people, intensity is a subjective element in their training program. Either they feel good or bad during a workout or they can or cannot hold a given pace.

In most cases intensity is misjudged by training at too great a level for the body to handle without breaking down. The cumulative effect of this is often the cause of failure in many training programs since it leads to inadequate recovery syndrome (IRS).

Signs and symptoms of IRS: increased resting pulse rate, overuse injuries, decreased performance, anorexia, fatigue, insomnia, weight loss, frequent infections, depression, mood disturbances.

Here’s what I recommend to prevent IRS:
- get a heart rate monitor and get a VO2 max test; this will give you the proper heart rate ranges to train in and it makes setting up a proper program EASY!
- monitor your heart rate first thing in the morning and keep a log of it in your training diary or calendar; if you see an increase of around 10 beats per minute from your average you have IRS
- do not train hard on back-to-back days
- do not increase the volume of your training by more than 15% per week

If you do end up with IRS take the entire next week off of training and get plenty of rest; then resume training at approximately 50% of your previous level until your heart rate drops to a normal range.

1. Don’t try out new shoes on race day. Have a few runs in the new shoes prior to racing in them. The consequences can be blackened toes, blisters, both, or worse. I once wore track spikes on a 7 km cross-country race. The shoes forced me up on my toes and I suffered calve strains for the next week. A friend of mine flew to a marathon and put on a new pair of shoes right before the race. On the way home he had to be taken off the plane in a wheelchair because his legs were so sore.

2. Don’t experiment with new gels, fluid replacement drinks, or food during races. Severe cramping, bloating, or diarrhea may result. I had an athlete who told me he wanted to try a gel during his marathon. I told him to try it on a few training runs before hand. He didn’t and took the gel at mile 10. By mile 13 he had severe cramping and his quest for a PB ended.

3. Don’t overindulge in alcohol at pre-race events. In years past, my team for the Jasper Banff relay was sponsored by a beer company. Selfless promotion of the product by myself the night before resulted in me taking water during the race starting at mile 1. Rule of thumb: 1 glass of water for each alcoholic beverage. Let your pain tolerance and conscience be your guide as to how many drinks you have.

2. What are the causes/predisposing factors of injury?
Usually repeated stress over time is the cause of this injury – especially lifting, bending and twisting activities. However, an acute tear of the annulus can result from a flexion (forward bending) trauma.

3. What are the symptoms?
Most often increased pain and limited mobility with forward bending is seen. You may also notice that you appear “crooked” or antalgic as your body tries to move away from the irritated area. In cases where a lumbar nerve root is involved there may be a sudden change from back pain to predominantly leg pain.

4. What can be done to prevent or treat this injury?
There are some studies to suggest that there is a lower incidence of this injury in cardiovascularly fit people and people who do not smoke. The hypothesis is that increased blood supply to the area around the disc promotes a healthier disc.

Treatment is varied and usually consists of icing the area, short term use of anti-inflammatories, ultrasound, electrical stimulation, McKenzie exercises, spinal manipulation, core stabilization and strengthening exercise, and aerobic conditioning. I recommend that people suffering from this consult their health care provider for assessment and treatment as these conditions can last for a long period of time. Also, if progressively worse neurological symptoms are seen (i.e. loss of bowl or bladder control) surgery maybe immediately indicated.

Sacroiliac joint syndrome involves dysfunction of the joint that is located between the sacrum and the ilium (hip bone). This joint normally has a small amount of movement that is required for proper mobility and is crucial for the transfer of weight from the trunk to the pelvis. Usually the dysfunction occurs as a loss of mobility within the joint itself, but can also involve a sprain injury to the ligaments that hold the sacrum and ilium together.

2. What are the causes/predisposing factors of injury?

Generally, this joint can be injured by too much backward bending (hyperextension), or if there is an overpronation problem with the foot that causes the joint to rotate posteriorly and become fixated (stuck). A flat foot can cause this too.

3. What are the symptoms?

Symptoms consist of a dull ache over the joint that can become sharp with backward bending. Referred pain that is dull in nature and can be felt in the thigh and down the back of the leg even into the foot is sometimes present.

4. What can be done to prevent or treat this injury?

Prevention should start with appropriate footwear to reduce overpronation if this is a factor. Most people are unaware if they have a functional problem with this joint, so an evaluation should be done if you fit the injury pattern as described above. Assessment of sacroiliac joint function involves specific orthopedic and palpatory testing that is usually done by chiropractors or those well versed in orthopedics.

Treatment of choice involves specific manipulation of the joint fixation to allow normal mobility and to the restore proper biomechanical and neurological function to the area. Inflammation or irritation of the area can be addressed with ice, anti-inflammatories and ultrasound. Rehabilitation that focuses on abdominal training and spinal-postural exercises are also used. Of note, I usually find an associated tight iliotibial band problem as part of this entity which must also be looked after.