Friday, June 28, 2013

Long Live Repetitive Eccentric Loading!

Got a call from my buddy, who injured his hamstring hurling (check out the Seattle Gaels website for some details about this awesome sport -

With hamstring injuries, there are two subtypes- proximal (near the buttock), and more distal.

Like with all tendon injuries, I recommend early icing and compression as mainstays of management.  There are different ways to ice, but my favorite is to use a gallon-sized ziplock bag, fill it 1/3 with ice, press out the air, and fold it back on itself with the redundant plastic.  I then slip it inside a compression short, so that you have both ice and compression.

Once the acute phase has been treated, the mainstay from an exercise standpoint is repetitive eccentric loading.  Eccentric strengthening exercises are exercises where the muscle is getting longer while you contract it- think of lowering a dumbbell after doing a biceps curl.  The hamstring is a particularly hard muscle to eccentrically load, so these are some Youtube links highlighting some good choices.


What should you do if you don't get better?  Well, that's obvious - come see Lake Washington Sports & Spine!  
- Diagnostically, we would do a thorough examination to make sure you don't have another injury (e.g., a lumbar radiculopathy, or SI joint arthropathy)
- If needed, we could look at the hamstring under ultrasound to assess the injury (3 times higher resolution than MRI!)
-Some patients benefit from ultrasound-guided injections, which we could do in the office.  We love the use of ultrasound- it hurts less, more accurate, more likely to work, and cool to see.  We're all about the patient experience at Lake Washington Sports & Spine.

Heal up buddy!

Monday, June 24, 2013

Journal Club: The "Ouch" Trial- Outcomes of Usual Chiropractic Care

Reviewing the OUCH trial

Outcomes of Usual Chiropractic; Harm (OUCH). A randomised controlled trial. Spine 2013 June 17, Walker BF et al

  • This study was performed in 12 chiropractic clinics
  • Compared 92 patients receiving normal chiropractic care to 91 patients received a sham intervention.  Sham interventions included:
    •  de-tuned ultrasound
    • an Activator instrument, a hand held device that delivers a low impulse, wound to lowest output and administered on the back randomly through a tongue depressor to disperse any remaining force
    • a randomly placed hand on the spine while ultrasound was administered to give a “hands on” experience
  • Patients were assessed for adverse events using a questionnaire
  • No severe adverse events were reported
  • Relative risk (i.e., comparing the risk of chiropractic care vs sham intervention) was assessed for several criteria
    • adverse event occurrence
    • severe adverse events
    • adverse event onset
    • adverse event duration
  • In all cases, there was no statistically significant difference in adverse events between chiropractic care and sham intervention

Bottom line: What does this mean for our patients? 
  • Chiropractic care, like all interventions, has some risk of adverse events.  However, those risks may be overstated, and at least in this study, did not occur more frequently than sham interventions
  • When considering treatment options, chiropractic care is not usually being compared to doing nothing, but rather is being compared to other treatment modalities that also have risk, including other manual therapies, medications, injections, or surgery
    • For perspective, the annual death toll from NSAIDs, the most common form of anti-inflammatory medication (e.g., ibuprofen), is estimated to be between 3,200 - 16,500 annually, far higher than from chiropractic care
  • We believe that chiropractic care, in appropriately selected patients, is a helpful modality, and should be considered as a treatment option
  • Our approach at Lake Washington Sports & Spine is to provide patients with a breadth of treatment options, inform them of risks and rewards, to help empower patients to make the right choice for them

Thursday, June 20, 2013

Journal Club: A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections

The Journal of Bone and Joint Surgery, one of the leading orthopedic journals, has published this recent article on the risk of vertebral compression fractures

First, this is a well designed retrospective study.  All retrospective studies have some limitations because of some biases that can affect reporting, so that must be kept in mind.  The sample pool was a total of 6000 patients out of a database of 50,345, which is a large study.

The looked at 3000 patients who has lumbar epidural steroid injections, and compared these patients to 3000 with low back pain who did not have an epidural steroid injection.

No significant difference was found between the two groups in terms of their baseline characteristics.  However, the risk of compression fractures did increase with additional injections.

Bottom line: What does this mean for our patients?  
- Spine injections can be a helpful to manage patients with spine conditions, and we perform these injections with guidance (either fluoroscopy or ultrasound) to minimize the need for multiple injections
- One of the risks with any type of corticosteroid injection ("cortisone shots") is that it can weaken bone, including possibly causing a compression fracture
- The risk of compression fractures did increase when patients had multiple injections
- Because of this risk, the physicians as Lake Washington Sports & Spine take care to work with the patient to make sure they understand the risks associated with any decision to have an injection
- We pride ourselves on trying to minimize the total number of injectons the patient needs.  It is common for patients to be offered a "series of three" injections, in hopes that one injection may work.  That is not our general approach.  Every decision to have any an injection, including more than one injection, is treated with the respect we would want for our family members and loved ones

Lake Washington Sports & Spine physicians highlighted at American College of Sports Medicine Annual Meeting

Garrett S. Hyman, MD, MPH, and Gary P. Chimes, MD, PhD, were featured at the American College of Sports Medicine Annual Meeting in Indianapolis, in May of 2013.

The American College of Sports Medicine ( is the world's largest organization promoting sports medicine, exercise research, health, and wellness.

Dr. Hyman was the Course Leader for the Diagnostic Musculoskeletal Ultrasound course, teaching other physicians in the use of Musculoskeletal Ultrasound for treatment of sports injuries.  We are proud that Dr. Hyman was recognized as a national leader in the use of this exciting modality to help better diagnose and treat patinents!

Dr. Chimes also participated in the Musculoskeletal Course as a lecturer and instructor.  Additionally, he lectured on the topics of assessment of the spine in athletes,  and served as a panelist on case presentations for athletes with spine pain.

The physicians at Lake Washington Sports & Spine strive to provide the highest level of care for Sports, Spine, and Musculoskeletal injuries, and will continue to work with leaders at the ACSM and other organizations to help train the next generation of physicians.
Lake Washington Sports & Spine endorses Physical Activity Bill

The American College of Sports Medicine is reaching out to promote Physical Activity Guidelines for Americans Act.  The physicians at Lake Washington Sports & Spine feel that regular physical activity is essential for the health and wellness of our patients, and therefore have contacted our representatives to endorse this act, which would promote the development of physical activity guidelines.

To learn more about this bill, you can read the actual text at the bill at the following link:

For the news release from the American College of Sports Medicine:

Thursday, June 13, 2013

Welcome to our new company blog!  
This space will be used to share a variety of information, all relating to the promotion of wellness and prevention of injury.  
It is our sincere hope that this blog will help our patients (both current and future) make better, more informed choices about their personal health and well being. 
More to come soon!