Shoes, Uniform, Ball … Mouthguard?


By Polly Blake Buckey, D.D.S., M.S.


Mouthguards are a vital, often overlooked, piece of equipment in the athlete’s arsenal, particularly when competing in contact sports.  This is not an outrageous claim, considering that dental injuries are the most common type of injuries sustained in sports.  Anyone participating in a contact sport has at least a 10 percent chance of sustaining an orofacial injury.  You are 60 times more likely to be injured when not wearing a mouthguard.

The teeth most often traumatized by these facial injuries are the central and lateral incisors (front four teeth), which account for four-fifths of all cases.  A total of five million teeth are knocked out each year.  If these teeth are not properly preserved and replanted, dental costs to treat these traumatized teeth can range from $10,000 to $15,000 each, not including the costs of treating the gums and bone around the teeth.

Mouthguards prevent teeth from perforating soft tissues, such as the lips, tongue and cheeks.  They also play a crucial role in stabilizing the temporomandibular joints and are helpful in preventing jaw fractures.  However, the biggest asset of wearing a mouthguard may not be the protection that they offer to the teeth; a properly designed mouthguard reduces the incidence of concussion by absorbing the majority of the impact dealt to the mandible during a sharp blow.


Three types of mouthguards available:

  • Stock mouthguards are fairly rigid shells designed to be worn without further modification.  Often they have adequate mechanical properties, but the generally poor fit hinders speaking and breathing.  This likely leads to low user compliance.
  • Mouth-formed guards tend to be bulky and deteriorate fairly quickly.  These guards are formed by boiling the material in water, cooling it slightly and biting into it to adapt it to the teeth.  Initially the mouthguard may fit, but repeated usage causes lost retention as the unit slowly hardens.
  • Custom-made mouthguards are fabricated by the dentist by molding thermoplastic sheets to a cast of your child’s mouth.  This type of mouthguard provides the most optimal comfort and fit, with the close adaptation allowing for ease of speech and breathing.  The only drawback to custom mouthguards is a greater cost.

The success of the mouthguard speaks for itself.  In sports where the use of a mouthguard is mandated, there are simply fewer injuries than in other sports where no such rule exists.  But why are orofacial injuries not completely eliminated?  Often it is not a lack of rules, but a lack in enforcement of the rules.  In college hockey, a referee will not stop play simply because a player isn’t wearing his mouthpiece; however, referees in NCAA football watch for mouthguard use and will throw the penalty flag if there is an infraction.

Mouthguards should be introduced to children, as they are more willing to comply with usage and can develop positive attitudes about wearing them in order to reduce the number of orofacial injuries sustained during their athletic endeavors.  As a child’s mouth continues to change in size and number of teeth, a new custom-made mouthguard will need to be fabricated.  Check with your child’s dentist to see if he or she recommends a mouthguard to help protect your child while playing a sport.


Polly Blake Buckey, D.D.S., M.S., is a pediatric dentist.  She graduated from the University of Michigan’s School of Dentistry in 2000 and earned a master’s degree in pediatric dentistry from the University of Michigan in 2002.  She was the director of the dental clinic at Kosair Children’s Hospital from 2003 to 2006.  She loves working with children and making sure every child has the best care possible. 

Shin Splints: What are they really?


By Stephen Karam PT, DPT,

In the lexicon of medicine, “shin splints” is yet another phrase that has a specific and real definition.  The real name for this condition is called Medial Tibial Stress Syndrome (MTSS).  That sounds much worse and more ominous than “shin splints.”  MTSS generally presents as pain just along or right behind the shin bone (tibia).  It is pain caused by inflammation or disruption of tissue that connects the the muscles of her lower leg to the tibia.  Fortunately, MTSS is very curable and rarely requires a medical procedure other than a visit to your Physician or Physical Therapist to diagnoses it properly.  It is a common injury that is seen frequently in runners and athletes that have to play on hard surfaces or those who have to start/stop frequently.

MTSS can develop into more serious conditions such as a stress reaction/fracture or compartment syndrome.  It is also very important to rule out these 2 conditions before MTSS is ruled in.  Signs of something worse like compartment syndrome may include redness, hotness, significant swelling or feeling of pressure building in your lower leg.  Signs of a stress reaction may include pain at rest, pain for a long period of time and increased pain in a weight bearing or standing position.

Risk Factors of “shin splints” may include:

  • Tight/stiff muscles of the legs and gastrocs
  • Worn down or old running shoes
  • Runners who over pronate or who have flat feet
  • Runners who are beginning a new running program
  • Individuals participating in high impact, high intensity sports/workouts

Tips to manage or prevent shin splints:

  • Wear appropriate shoes or arch support for your foot shape and mechanics
  • Warm up before activity and stretch afterwards
  • Ice or cold treatment to shins when painful
  • Participate in less impact activities like swimming, biking, elliptical
  • Listen to your body when it is in pain

Most health insurance plans now allow patients to seek physical therapy treatment directly without a physician referral.

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Clinic Director Stephen Karam PT, DPT, earned his doctorate in physical therapy from the University of Kentucky after completing a bachelor’s degree in exercise science. He is a member of the American Physical Therapy Association (APTA). He specializes in manual therapy with a strong emphasis in orthopedics and sports medicine. In his spare time, he enjoys tennis, working out, music and football.


The Use of Prophylactic Bracing In Sports


By Stephen Karam PT, DPT

Unfortunately, knee and ankle injuries have a high incidence rate in both football and basketball.  Physicians, trainers and athletes have tried and are willing to try just about anything to prevent one of these injuries from occurring.

If you have been watching college or professional football over the past 10-15 years, it would be hard not to notice large, bulky knee braces on the entire offensive line.  These large, bulky braces come with a large, bulky price as well and are “supposed” to prevent serious knee injuries from occurring allowing these players to stay on the field.  Some of these injuries include meniscus, MCL, ACL and damage to the articular cartilage of the knee.

So do these expensive, large braces prevent these devastating injuries from occurring? 

In a 2010 issue of the Journal of Sports Health, Salata et al conducted a systematic review of 6 articles that studied the use of knee braces in football and injury prevention.  The systematic review suggests that there may be limited protection of the MCL and that there is no evidence that wearing these prophylactic knee braces prevent injuries to the ACL and meniscus.  One of the articles in this systematic review suggests that wearing these braces may even increase the risk of injury to knees, ankles and feet.  At this time there is not enough significant medical evidence that suggests wearing these knee braces prevents serious injuries from occurring in football. Due to the “ounce of prevention is worth a pound of cure” theory, college and professional budgets allow for any and all measures of prevention to be taken whether or not it has a high value of efficacy.

On a positive note there is significant medical evidence that supports that use of ankle braces in prevention of ankle sprains in basketball.  A 2011 study by the American College of Sports Medicine looked at nearly 1500 male and female basketball players from 46 high schools.  The incidence of ankle injury in the braced group was .47 per 1000 exposures and 1.41 per 1000 exposures in the control group.  Demonstrating a significant difference in those athletes wearing braces and those athletes who were not wearing the provided brace.  The study did note that there was not a significant difference in severity of injuries between the braced and controlled groups.  In contrast to the knee braces these lace up ankle braces are affordable and probably should be considered as a method to prevent ankle injuries.

Please consult your Physical Therapist or Athletic Trainer before purchasing or fitting for one of these prophylactic braces as wearing the wrong size may increase your risk for injury.

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KORT Chevy Chase Clinic Director Stephen Karam PT, DPT, earned his doctorate in physical therapy from the University of Kentucky after completing a bachelor’s degree in exercise science. He is a member of the American Physical Therapy Association (APTA). He specializes in manual therapy with a strong emphasis in orthopedics and sports medicine. In his spare time, he enjoys tennis, working out, music and football. For more information go to:

Regional Interdependence: Treat the knee without treating the knee.


By Josh Bixler PT, DPT

           Picture this: You’re an avid runner and you’ve recently ramped up your training for the upcoming mini-marathon.  In doing so, you’ve developed some nagging pain in your right knee.  Being the pro-active person you are, and aspiring to do well in the race, you decide to seek the care of a physical therapist.


During the evaluation, the physical therapist takes a thorough history from you, examines your right knee, but also assesses the rest of your body.  They end up treating your left foot and providing home exercises for your hips and trunk.  Curious as to why this was the choice of treatment, since the right knee is clearly the source of pain, not the hips or the foot, you ask the therapist for clarification.  The therapist responds “regional interdependence.”  They explain that your left foot lacks the mobility (motion) you need, your hips and trunk are weak, and it appears these deficits caught up with you during your training.


In this instance the right knee was the victim, and the foot and hips were the problem.  The therapist went on to explain the importance of looking at the body as a whole, and not chasing symptoms.  With this treatment approach, they feel confident you’ll be back to pain-free running in no time.


The aforementioned case is one example of the musculoskeletal examination model termed “regional interdependence.”  Regional interdependence is the concept that potentially unrelated impairments above and/or below the patient’s area of complaint; this is necessary to determine if those areas are contributors or not.  Intervention is then applied to those areas deemed as impaired with the expectation of producing a result at the source of complaint.  The interventions could be anything from hands on techniques to exercise.  The result could be improved range of motion, decrease pain, or improved strength just to name a few.  Now this is not to say the area of symptoms is not impaired, it very well may be, however there are often additional areas involved that may have contributed to the problem and deserve attention.


The regional interdependence model came about due to the need for a better approach to explaining and treating musculoskeletal and treating musculoskeletal disorders.  As the field of rehabilitation has progressed, so too has our knowledge of how the body works and the limitations of the old approaches to treatment.  It is important to note that regional interdependence applies to addressing impairments above and below one’s source of symptoms, and not that of referred pain, or pain being felt in a different area from the actual source.


Given this information, you might be saying to yourself, “This concept sounds great in theory, but is there evidence to support it?”  Absolutely!  The current literature has many articles referencing regional interdependence either directly or indirectly.  The literature contains thoracic spine (mid-back) interventions for the cervical spine interventions for the shoulder; cervical spine interventions for the elbow; hip interventions for lumbar spine (low back); hip, ankle, and foot interventions for the knee.


Clinically speaking, assessments of an athletic population may involve impairments even further up or down the body.  When assessing a baseball pitcher with elbow or shoulder pain, one must not only look at those areas, but also consider the neck, shoulder blade, thoracic spine, lumbar spine, hips, legs, knees, and feet.  This approach is similar for runners, where abnormal breathing patterns could also potentially contribute to impairments.


With the acceptance and growth of the regional interdependence examination model, assessments have been developed to further assist healthcare professionals.  One of those assessments is the Selective Functional Movement Assessment, or SFMA.  The SFMA is a tool that allows clinicians to assess patient movement patterns starting at the neck and working down to a body-weighted squat. From there, movements identified as “dysfunctional” can be further broken down into mobility versus stability problems.  This approach, along with best current evidence and clinician expertise, can help guide the clinician with decision making.


In a time with rising healthcare costs and with money tight, patients have come to want and expect care that produces meaningful outcomes.  In the case of the runner, the right knee was the victim and a thorough assessment using the regional interdependence examination model helped to “treat the knee without treating the knee.”


DO you have pain or just a want to take a pro-active approach like this runner?  Consult your physician, the professionals at KORT, or visit www.kort.come to learn more.


KORT Old Brownsboro Crossing Clinic Physical Therapist Josh Bixler
 PT, DPT, graduated with his Doctorate of Physical Therapy from Bellarmine University, and also has a BS in Exercise Science from the University of Indianapolis. He is currently finishing up an orthopedic residency and is trained in using both the Selective Functional Movement Assesment and Functional Movement Screen. Josh is a University of Michigan sports fanatic (Go Blue!) and also enjoys rooting for the Colts, White Sox, and Red Wings. His personal interests include anything relating to physical therapy, injury prevention, fitness, nutrition. For more information go to

Dealing with Carpal Tunnel Syndrome

By Kellye Olson, OTR/L, CHT

Everyone knows someone who has had or does have carpal tunnel syndrome.  The first question I usually get asked when people find out that I’m a hand therapist is, “do you think the pain in my hand could be carpal tunnel?”  Carpal tunnel syndrome (CTS) is very common in the hand, but just because you have pain in your hand doesn’t always mean you have CTS.  There are not only more specific symptoms you can have other than just pain, but those symptoms occur in specific parts of your hand.

Look down at your right wrist, palm side up.  At the bottom of your palm, just above where your wrist and hand meet lies your carpal tunnel.

The carpal bones of your wrist serve as the floor of the carpal tunnel.  Passing through the carpal tunnel and over the carpal bones are nine flexor tendons and the Median nerve.  Everything is held nice and tight within the carpal tunnel by the Transverse carpal ligament that spans over the top of the nerve, tendons, and carpal bones.

Diagnoses such as arthritis, pregnancy, and diabetes can cause the pressure within the carpal tunnel to increase and cut off nutrition to the nerve.

Other times, the wrist is held in a flexed position for long periods of time and the nerve gets compressed within the carpal tunnel, also cutting off nutrition to the nerve.  People who fold their hands into their blankets at night are prime candidates to have symptoms of CTS.  They tend to sleep with their wrists in this flexed posture, compressing the Median nerve for a prolonged period of time, and waking up because their hand is still very soundly, and very painfully, asleep.   When the nutrition to the Median nerve is compromised, it can send out distress signals in the form of pain, but more specifically people feel numbness and tingling in the thumb, index, and long fingers.

The CTS is usually pretty easy for a Certified Hand Therapist to diagnosis and treat.  Therapy for CTS spans from learning how to do the appropriate stretches and changing positions all the way up to custom splinting to allow the median nerve time to rest and recover.

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Kellye Olson
, OTR/L, CHT earned her Bachelor of Science in occupational therapy from Eastern Kentucky University in 2004 after completing a Bachelor of Arts in Psychology from the University of Kentucky in 2000, and is currently pursuing her occupational therapy doctorate with an emphasis on hand therapy from Rocky Mountain University of Health Professionals. She became a Certified Hand Therapist in 2011, which requires a therapist be an OT or PT, have at least 4,000 hours in hand therapy experience, and pass a comprehensive exam of advanced clinic skills. Kellye also has experience with industrial job site analysis, functional capacity evaluations, and industrial rehab. She is a member of KOTA and the ASHT, as well as an Alumni member of the Taylor County/Campbellsville Leadership program. Previously from Lexington, Kellye has worked in Campbellsville, KY for 3 years and is now returning to the area to begin a hand therapy program for KORT Lexington at the Bryan Station location.


What is Trigger Point Dry Needling and Can It Help Me?

By Janelle Ciolek, PT, DPT, OCS

Trigger Point Dry Needling (TDN) is a treatment technique utilized by specially trained Physical Therapists to help treat neurogenic and musculoskeletal pain of either chronic or acute nature.  Many people with pain conditions are found to have active Trigger Points (TPs) in muscles, which exacerbate their pain.  Trigger points are taut, banded, irritable spots within skeletal muscle that cause pain, especially when they are compressed.  In scientific studies, trigger points have been found to demonstrate irregular electrical activity and shortened muscle structure, along with having pain causing chemicals within the muscle tissue.  These trigger points will often cause pain referral to other adjacent areas.  For example, a trigger point on the back of the shoulder blade, when compressed, may reproduce pain in the front of the shoulder or down the arm.

During treatment with dry needling, the physical therapist inserts a flexible, thin filament needle directly into the painful trigger point. The patient can feel a variety of sensations, most notably a deep aching or cramping sensation, and often will experience a localized muscle “twitch” sensation.  These sensory experiences help guide the treatment and let the therapist know they are treating a problematic area.  Dry needling, through scientific research, has been shown to promote healing in the affected painful areas.  It does this by releasing muscle tension, quieting electrical activity in the trigger points, and decreasing the chemical factors in the trigger points that cause pain.

Trigger point dry needling, in the hands of the trained and capable physical therapist, can be used to treat almost any musculoskeletal condition, including back pain, whiplash, frozen shoulder, elbow tendonitis, and plantar fasciitis, amongst many others.  It can even be used post-surgically to treat hypertrophic or adhered scar tissue.  Dry needling is used as valuable part of the whole physical therapy “package” which can include therapeutic exercises, joint mobilization or manipulation, patient education, and modalities.  Every patient has a unique program developed specifically for them, based on their symptoms and needs.

The American Physical Therapy Association as well as the Kentucky Physical Therapy Association support the use of trigger point dry needling in the hands of trained and licensed physical therapist.  For more information, please visit

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Janelle Ciolek PT, DPT, OCS, is the Clinic Director and has been part of our KORT team since 2005. Janelle is a 2004 graduate of the Doctor of Physical Therapy program at Bellarmine University, a Board-Certified Orthopedic Specialist (OCS), a certified  IASTM therapist, practitioner of Functional Dry Needling (FDN) and is a Clinical Instructor for the American Physical Therapy Association (APTA). Janelle also serves as adjunct faculty in the Bellarmine University Physical Therapy Department. Janelle loves the fast-pace and challenges of outpatient orthopedic physical therapy and has substantial experience in this area. Her clinical interests include manual therapy, sports injuries, and knee and shoulder reconstruction.


Chronic Pain: The False Alarm

By Chad Garvey, PT, DPT, OCS, FAAOMPT

Everyone who has heard a car or house alarm over and over again in their neighborhood understands how annoying, stressful, and unhelpful they can be.  It doesn’t serve its purpose anymore and only makes life more miserable for everyone within earshot of it.

Chronic pain behaves very similarly in the body, and its message is not only inaccurate, but having it makes everything else in your body unhealthier.  1 out of every 6 people lives with chronic pain and 75% of those adjust their lifestyle because of it.

So how do you turn the alarm off?  There is a growing amount of research in this area with good news!  You can help manage this alarm system and “turn the volume down”.

One of the best 1st options is regular aerobic exercise. This can be as simple as a daily 5-10 minute walk to start, as long as it is something that doesn’t cause the pain to “flare up” and increase stress chemicals in the body.  This type of activity helps produce “feel good” chemicals in the brain which can help “rewire the alarm”.

Another technique is visualizing the activity, pain free, that normally accompanies pain, paired with deep, slow breathing.  This also helps “rewire the brain” by preventing the pain from being expected every time the activity occurs.

These are just a few of the activities that can be done to effectively help the brain “relearn and rewire” itself to better know that “PAIN DOES NOT ALWAYS EQUAL HARM.”  To learn more about chronic pain and how to better deal with it feel free to speak with a KORT physical or occupational therapist to gain more strategies and education about dealing with chronic pain. Visit us at or call 1-800-645-KORT.

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Chad Garvey KORT Downtown Clinic Director, PT, DPT, OCS, FAAOMPT earned his Doctorate of Physical Therapy from Regis University as well as a post-Doctoral Certificate in Manual Therapy. He is a Board Certified Specialist in Orthopaedic Physical Therapy (OCS) and is a Fellow in the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). In addition, Chad is a certified Strength and Conditioning Specialist (CSCS). Chad is the clinic director. He is a lead instructor for KORT’s orthopaedic residency program in addition to being an instructor to practicing physical therapists and physical therapy students at both the local and national level. He regularly conducts and shares his own research at national physical therapy conferences.

Sodium, Muscle Cramps and Sweat Losses: Tips for Sweaty Athletes

By Nancy Clark MS RD CSSD

We’ve all heard the stories about marathoners and soldiers who have died due to consuming too much water. Clearly, overhydration can be as dangerous to your health as underhydration. So what does a sweaty athlete need to know about staying adequately hydrated without stomach sloshing? Dr. Timothy Noakes’ book Waterlogged: The Serious Problem of Overhydration in Endurance Sports is an interesting yet controversial resource that addresses that question.

According to Dr. Noakes, the sports drink industry has effectively marketed a positive image (successful athletes) despite having an overhyped product (salted sugar-water). Noakes believes the sports drink industry has brainwashed athletes to overhydrate—and this has created life-threatening problems. For example, between 1983 and 1998, more than 700 cases of exercise-induced hyponatremia (overhydration that leads to low blood sodium, brain swelling, coma, and even death) were documented in the Gatorade-sponsored Ironman Hawaii  Triathlon. The participants had been  encouraged to drink copiously. Did that advice backfire? For the Comrades Marathon, participants were told to drink according to thirst. Race organizers placed aid stations every 5 km (3 miles) and cases of hyponatermia dropped.

The information in Waterlogged challenges the theory drink before you get thirsty. Noakes believes elite athletes who become champions can tolerate significant sweat loss without untolerable thirst. He contends the associated weight lost via sweating enhances performance. Others question if those athletes could run better if better hydrated!


Below are a few droplets of less-controversial hydration information to help you quench your thirst, perform well, and stay out of the medical tent when you are doing extended exercise in hot weather.


• Our bodies can deal with transient underhydration that lasts from 4 to 8 hours. In contrast, chronic dehydration leads to health issues—such as happens when elderly people are trapped in hot apartments during a heatwave.


• Most athletes feel thirsty at about 2% dehydration. At that point, they’ll start looking for water. Ultrarunners can maintain performance at 3% dehydration. (To determine your percent dehydration, weigh yourself naked before and after your workout. A one-pound drop equates to a loss of 16-ounces of sweat; 2% dehydration equates to a 3 pound sweat loss for a 150-lb. person.)


• Thirst is a powerful fluid regulator. Noakes disapproves of the advice to drink before you are thirsty because that can create problems with overhydration. Yet, others contend drinking on a schedule can help endurance athletes maintain proper hydration, as long as they do not aggressively overhydrate but rather replace fluids according to their sweat losses (as learned during training via pre-post exercise weigh-ins).


• Exercise-induced hyponatremia (low blood sodium) occurs when athletes drink excessively during prolonged exercise. It can also occur when even dehydrated endurance athletes lose significant amounts of sodium in sweat. Data from 669 ultramarathoners indicates 15% experienced low blood sodium. Of those, 24% were overhydrated, 36% were dehydrated, and the rest were in fluid balance (but not sodium balance) (1).


• The amount of sodium lost in sweat varies from person to person. Some people are salty sweaters. Athletes accustomed to exercising in the heat retain more sodium than unacclimatized athletes. (Compare the saltiness of your sweat on first hot day of spring vs. in the fall.)


• Athletes lose relatively more water than sodium, so under standard conditions, the blood sodium level can actually increase during exercise (unless you overhydrate). But with abnormally high sodium high losses, such as during an ultramarathon, blood sodium can be low even in a dehydrated athlete. Hence, sodium replacement can be a wise idea.


•The amount of sodium in a sports drink is small—and unable to counter the dilution of body fluids that occurs with over- drinking. The 220 mg of sodium in 16 ounces of Gatorade is far less than ~1000 mg sodium in 16 ounces of sweat loss.


• Noakes says evidence is lacking to prove that athletes who cramp have low serum sodium or are more dehydrated than non-crampers. He suggests muscle cramps are related to fatigue, not sodium deficiency. If sodium deficiency was the problem, wouldn’t the entire body cramp, not just one muscle?


• Exercise-induced muscle cramps occur in muscles that perform repetitive contractions. Athletes who get cramps tend to be those who do high intensity exercise, as well as those who have a history of cramping. Note: Many exercise scientists believe there are two types of muscle cramps: some related to fatigue, others related to sodium imbalance. The science of cramping lacks a clear consensus!


• Stopping exercise to stretch resolves muscles cramping. (Stretching also resolves nocturnal cramps.)


• A 2.5 oz. mouthful of (salty) pickle juice has been shown to alleviate muscle cramping within 90 seconds of drinking the pickle juice. This rapid benefit is unlikely due to changes in blood sodium levels—too quick! Noakes speculates drinking the (acidic) pickle juice triggers a reflex in the throat that lessens or stops the cramps.


• An athlete who collapses after the finish line is most likely experiencing blood pressure changes—not severe dehydration. When exercise stops, the heart stops pumping enough blood to the brain; the athlete collapses. Noakes advises to quickly raise the athlete’s feet and pelvis above the level of their heart. This aids the return of blood to the heart and rapidly corrects the situation—without any IV fluids.


So what’s a sweaty endurance athlete supposed to do during prolonged exercise? Learn your sweat rate and drink accordingly. If fluid in your stomach starts “sloshing”, stop drinking! The body can absorb about 600 to 1,000 ml/hour (women/ men). Adding carbohydrates and sodium to the water enhances fluid absorption as well as palatability and performance. Consuming “real” foods (salty pretzels, pickles, chicken broth, ham-cheese-mustard wrap) during ultraendurance events can do a fine job of providing needed electrolytes. Just don’t get too aggressive with water or sodium intake—and have fun!

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Nancy Clark, MS, RD, CSSD (Board Certified Specialist in Sports Dietetics) counsels both casual and competitive athletes at her office in Newton, MA (617-795-1875). Her Sports Nutrition Guidebook and food guides for new runners, marathoners, and soccer players offer additional information. They are available at See also



1. Hoffman M, Hew-Butler T, and Stuempfle K. Exercise-Associated Hyponatremia and Hydration Status in 161-km Ultramarathoners. Med. Sci. Sports Exerc. 45(4):784–791, 2013.

Swimming Associated Shoulder Injuries

By J. Steve Smith, MD

As a general rule, it is difficult to find a sport or exercise that is more healthy than swimming.  This athletic activity is outstanding for cardiopulmonary fitness, muscle strength, joint preservation, and stress relief.  It’s actually pretty rare for an athlete to suffer an injury from everyday swimming.  However, as with any endurance sport, overuse injuries do occur and they are almost always related to competitive swimming events (e.g. the Ironman).  Young athletes are also prone to this type of shoulder injury because they swim in multiple venues, i.e. high school, club teams, and private lessons.  In fact, a study showed some swimmers have as many as 16,000 shoulder revolutions in a week, with the potential of one million shoulder revolutions per year.  By comparison, a baseball or tennis player will have 1,000 shoulder revolutions per week.  Thus, there is a tremendous strain placed on a swimmer’s shoulder.

Any overhead sport can lead to a myriad of common shoulder complaints and symptoms, and swimming is no different.  The etiology of shoulder pain from the swimming stroke most often comes from rotator cuff tendonitis.  This condition, sometimes referred to as tendinopathy, is usually a result of impingement of one of the four rotator cuff tendons on the bones within the shoulder.  The progression of this condition to significant rotator cuff tear is possible, but unlikely from this athletic activity.  This is important because full thickness rotator cuff tears often require surgical intervention, especially in active, healthy individuals, regardless of age.  If a patient is diagnosed with cuff tendonitis, then anti-inflammatories (e.g. Naprosyn or Ibuprofen), physical therapy, and ice are usually prescribed.  A corticosteroid injection is often given in the shoulder as well.  If these non-operative treatment regimens do not alleviate the discomfort then time off from swimming will be required.  Depending on the patient’s physical exam, aMRImight be necessary to further diagnose or rule out a significant injury.

All of the above mentioned modalities aid in recovery, but physical therapy is often the most important because the swimming stroke has a tendency to over develop certain shoulder girdle muscles while, at the same time, under develop other muscles.  In fact, there are 18 muscles that attach to the scapula (shoulder blade) and they all coordinate shoulder joint movements precisely.  Abnormal scapular motion, known as scapular dyskinesis, is a common result of multiple shoulder revolutions.  This condition can cause shoulder pain and functional loss because the shoulder “ball and socket” joint is malpositioned.  The glenoid (socket) is formed from the scapula and if the glenoid is not positioned correctly in space, then shoulder symptoms will occur.  Scapular dyskinesis is readily treated with physical therapy and time off.

The labrum is a ring of fibrocartilage that surrounds the glenoid and has several important shoulder functions such as deepening the socket and providing attachments for muscles and ligaments that give the shoulder some stability.  Overhead athletics, such as baseball, volleyball, tennis, and certainly swimming can injure this cartilage, especially if scapular dyskinesis is present.  AMRIis often necessary to confirm a labral tear, but if present, surgery is not a predetermined destiny.  Often physical therapy, NSAIDs, and time away from swimming will eliminate the discomfort.  Surgery may eventually become necessary, but not until all non-operative options are exhausted.

Overall, swimming is full of many more positives than negatives.  Any pain or injury as a result of this activity can usually be treated and eliminated with attention to proper swimming technique, changing up the swimming stroke (e.g. rotate freestyle, backstroke, and breast stroke), and cross training.  Endurance athletes relentlessly push themselves to achieve goals that many consider insurmountable.  I have a tremendous amount of admiration for their dedication, determination, and athleticism.  On the other hand, it is important for these competitors to remember that their sport, when taken to extremes, can lead to body breakdown.  Unfortunately, swimming is no exception.

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Dr. J. Steve  Smith is a Board Certified orthopaedic surgeon who specializes in sports medicine and arthroscopic surgery.  He has served on the medical team for the LA Dodgers, LA Lakers, USC football team, Ryder Cup, and currently for several collegiate and high school athletic teams.  He continues to speak at national meetings and publish research related to the advancement of sports medicine and arthroscopic surgery.  He is in practice at the Louisville Orthopaedic Clinic located on Dutchmans Lane.




The Effects of Vitamin D Deficiency in Athletes

By Stacie L. Grossfeld, M.D.

It is estimated that over 1 billion people are vitamin d deficient or insufficient. This is not just found in patients with medical problems but otherwise healthy elite athletes. Dr. Angeline et al from the Hospital for Special Surgery, in New York City, New York, published an outstanding article in the American Journal of Sports Medicine in Feb, 2013 regarding the effects of vitamin D deficiency in athletes.

Listed below are bullet points from their article.
1. Vitamin D deficiency is defined as serum levels of less than 20 ng/ml and insufficiency is defined as a level of 20 to 31 ng/ml. Vitamin D intoxication is defined as greater than 150 ng/ml.
2. Medical studies have found vitamin D deficiencies ranging from 40 to 50 % in dancers, patients undergoing ACL reconstruction or meniscal surgery. A recent study conducted by the Hospital for Special Surgery in New York found that out of 89 NFL players from a single team 51% were vitamin D insufficient and 30 % were deficient.
3. Sources of dietary vitamin D and intestine absorption of vitamin D a minor part of the total vitamin D requirements. The MAJOR source is from the interaction of the skin with UV light.
4. Vitamin D regulates the intracellular accumulation of phosphate within the muscles cells and this helps to maintain muscle function and metabolism.
5. Vitamin D receptor expression within muscle tissues decreases with age, which may provide a partial explanation as to why athletic performance declines with age.
6. Vitamin D’s active metabolite 1, 25(OH) D3 binds to the muscle nuclear hormone receptor, vitamin D receptor (VDR). Its pathway promotes gene transcription leading to increased cell protein synthesis and growth.
7. Studies in vitamin D deficient rats have shown that supplementation increases protein synthesis and muscle mass. There was also a decrease in the rate of exercise induced muscle apoptosis.
8. Muscle biopsy specimens from adults with low vitamin D levels have revealed atrophic changes of type 2 muscle fibers which are reversed with vitamin D and calcium supplementation.
9. Vitamin D deficiency is associated with limited sun exposure: sunblock use, region in the world, indoor training and dark skinned athletes.
10. Vitamin D supplementation may help improve athletic performance if the athlete is deficient. Unfortunately there are NO studies that determine the best level for the highest performance.
11. There are some studies that suggest that high level of vitamin D may be linked to other health problems such as tissue or kidney damage.
12. Vitamin D supplementation is best if 25(OH) D3 is used. D2 is only 30 % as effective as D3.
13. RDA recommendation for Vitamin D is 600 IU/day for children older than one year in age, adolescence and adults up to 70 years of age

14. RDA serum concentrations of 25(OH) D3 is between 30 to 50 ng/ml.
15. For the body to optimally absorb calcium the blood level of vitamin D must be at least 30 ng/ml.
16. If the body’s level of vitamin D falls below 30 ng/ ml it causes calcium to be mobilized from bone via parathyroid hormone and RANK-L. This can cause stress fractures and osteoporosis.
17. Calcium and vitamin D supplementation has been shown to decrease the incidence of stress fractures in female military recruits.
18. A link between vitamin D deficiency and decreased athletic performance has been known for years. Seasonal variability of athletic performance in the northern hemisphere was reported in the 1950’s. Peak performance occurred during late summer months and declined in the winter. Studies have revealed peak performance in the summer and lowest performance in the winter even with consistent training throughout the year. It’s maybe related to vitamin D levels.

19. UV radiation has been used in the past to improve physical performance: Russian researcher found in 1938 improvements in sprinters treated with UV radiation as compared to their non irradiated controls. The Germans in 1952 found increases in cardio fitness in children when exposed to UV radiation. The control group of children improved, to match the UV exposed group fitness levels, when given vitamin D supplementation. More recent studies have revealed an increase in muscle power, force, velocity and jump height in girls age 12 to 14 when vitamin D levels were optimized. Another more recent study found an increase in grip strength in teenage girls with normal levels of Vit D compared to the control group that was deficient.
20. Recommendation from the authors are to assess total serum 25(OH) D3 levels in high risk athletes and treating those that are deficient or insufficient.

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Stacie L. Grossfeld, M.D. is an orthopedic surgeon with Orthopaedic Specialists. She is
Board certified in Orthopaedic Surgery and Sports Medicine. For more information go to
www. or call 502-212-BONE (2663). Fb: Orthopaedic Specialists PLLC
YouTube: Louisville Bones.