Listener questions: surfing shoulder, CrossFit neck and knee pain

This is session number 51 of the Performance Place Sports Care Podcast. Ma! Let me love! Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey everyone, it's Dr. Sebastian Gonzales again with the Performance Place Sports Care Podcast. And if this is your first time, you should go back and listen to all the other episodes because we're into the low 50s right now. And I think we've come a really, really long ways.

I'm hoping these podcasts are getting better and you guys are learning more from them. And I'm hoping that I'm making them more entertaining because sometimes these sports injury topics and anatomy, rehab topics can be a little boring. But at the same time, I think that if you have them, if you have them, then it's actually, or they have the injury, a lot of times it's very interesting. So that's why I have this whole podcast out. Today, I'm actually going to answer some questions from some people who have written in with their stories. I thought these ones were good cases. One of them is going to be a knee injury.

Actually, this is in a lady who's about 60 years old or so. And she actually hurt her knee after going on a trip on a cruise. Another one's going to be a shoulder injury from surfing. There's going to be a neck one from lifting overhead or doing activities similar to CrossFit. And the last one's going to be a knee injury from golfing. So I'm going to go through each one just like that. And we're just going to read what they said and just kind of go a little bit more into recommendations and what I would kind of brainstorm with them if they come in. So if you are listening to this again for the first time, please go on to iTunes.

And if you're listening to on someone's website, go all the way through to iTunes and that's where you can subscribe and also review. So the reviews are really helpful to me because anytime I hear feedback from this, I try to improve the podcast. If you love it, tell me. Tell me the things you like. Tell me the things you hate. And share. Share this as much as you possibly can. And I've been surprised so many times how when people have heard this podcast or heard a topic on the podcast, how they thought it was more information than I would ever go to in person. And it's funny now. Actually, I have quite a few people that email or text me.

Some of my friends and family text me and they say, Hey, look, I was wondering about PRP. Then what do you know about that? And I basically did a podcast on it. I mean, I did do one on it. If you look back into the mid-20s, you'll see I had Dr. Goswami on. So I just sent him a link and they're like, Oh, cool. I didn't know you even had this. And I'm like, yeah, we talk about it for a full hour. So we have an expert right there and you can listen to it right then and there. So it's helpful for me to give better information rather than on the fly all the time, honestly. So go on to iTunes, share with friends.

If you know with my website, you know where it is. Go to p2sportscare.com slash podcast and it's all there too. If you want your question answered on air, you can leave it right there on the P2 Sports Care site as well. So that basically leaves a voicemail button. It really leaves a voicemail for me so I can listen to your words and basically get a minute and a half to kind of say your piece. And that's something I'll use in the air if it's a really, really good story. So let's start first with this new one. I'll read this for you guys. So it says, hi, I'm dealing with a knee injury that has stopped me from dancing for a few years.

I started when I was on a, or it started when I was on a trip where I was walking around on a bunch of stairs on a cruise, on a cruise liner. So I, I was on the, it was okay when I was on the trip, but I, it started to hurt on the inside of the knee within a week of coming back. I've been seeing an insurance recommended physical therapist who gave me some modifications like sleeping with a pillow under the knee, how to ice it, some stretching exercises as well. I have stopped working out because squatting seems to increase pain. It seems to be getting better, but is, but I still feel it from time to time.

Is there anything I can do or is there anything that I missed? Sorry if my reading on that's pretty bad. I remember that actually that thing, popcorn in school. I don't know if you guys had it too, where basically you'd have to read like three or like a paragraph in a book and the teacher would say popcorn and then you would, it'd point to someone else. And I hated it. I hated it because I'm better on a fly like this, I think with talking unscripted rather than having something in front of me. So anyways, let's, let's break down and digest a little bit with what's going on with her. The first thing I think about with knees anyways, and considering we don't really know anything about, does she have a really, really severe arthritis?

Probably not because she didn't have pain before she went on the trip. There was some type of incident or increase of usage, it sounds like. So she was walking a bunch of stairs. Also too, the fact that it was on a cruise line or a ship makes me think instability or an unstable platform of motion mainly. And the reason why that's important is because if you've listened to the knee podcast that we've done in the past, by the way, if you haven't, you really should. If you have a knee condition, there's two right in a row that are great. I think they're 31 and 32, if I think about it. So anyways, with knees, they don't like rotation.

They don't like it because it typically irritates the cartilage, it irritates the ligaments around it, irritates some of the tendons and muscles. It's just the way it goes. So the knee is just kind of stuck in the middle there and it doesn't like to rotate. But that doesn't mean that we shouldn't subject us to some type of rotation or even lateral bend, which is side to side kind of. If you don't know what these movements are still, they're the ones that are basically not bending it forward backwards where the knee moves a ton of. So the knee on the cruise line, or I can imagine walking steps, you kind of hit a bump in the ocean and it kind of wavers you a little bit and just kind of tweak it slightly.

So over and over again, it could irritate. And I know I haven't gotten to the probable diagnosis of it yet. By the way, it's probably some type of meniscal tear since it's the inside and just what it sounds like. But it could be a lot of different things. But it sounds like, I mean, the theory on with rehabbing the knees is typically that we want to subject it to some type of rotational and lateral bend force, a little one. And in a controlled setting, such as doing lunges with a band pulling your hips rotationally, or say doing a paloff press is another example, like a lunging paloff press. These are exercises that typically will create some type of rotational moment that the goal is to still do the lunge or the squat or the deadlift or whatever we're doing, whatever the movement is, and still have good tracking or good form with it.

Now, it doesn't take a lot of load to do this. But the reason why we do it is almost to like, I think I talked about it in the podcast about knee conditions, is that we were talking about snake venom. And so the anti-venom is basically made of snake venom, but it's kind of reverse engineered, right? So to become immune to the venom, you have to take small doses of it. And this is kind of how they suggest like evolution kind of happened, right? Eventually, people just kind of lost their tails, they say. So it's, if you subject, if you should just subject the person's knee or this person's knee to rotational forces safely and making them aware of what they're supposed to do, strengthening the core, strengthening the hips, then we can save them from irritating on something like walking a bunch of steps on a cruise liner.

Which, it's funny, I've never heard anyone injure themselves that way, but it sounds like it could be a definite, definite onset. So she said it took about a week for it to happen after that, which does make sense. A lot of times, not all these injuries are trauma-based. So trauma would be more of a someone slipped and fell into her knee and then it really popped it. The other types is kind of a build-up condition, or I guess they would say overuse, or I like to say atraumatic, because it doesn't always have to be overuse either. But atraumatic is just kind of a build-up process. Like, it's usually a movement-based disorder.

You're not moving well, which will typically irritate an area, crush an area in the case of a meniscus, stretch an area in the case of a tendon or a muscle, and make it basically become super irritated over time. So sometimes it takes a little bit of time for those things to onset. But it's a movement-based disorder typically. It's usually not that it was the fault. It's usually not the fault of the structure currently. And I'll bring it back to what she was saying or what her condition is. So if we have a meniscal injury, sometimes that compression of it, just the slight compression of it, is enough to irritate and create some pain in the area.

It doesn't mean that the area or the meniscus is actually damaged yet. It could be damaged in the future, but it might not be damaged yet. And what I mean by that is meniscus or cartilage of at least that type, they get some of their nutrients through kind of compression. And think of a sponge. You compress it, and you let it go. Like, you're pushing stuff out and sucking stuff in and so on. So a lot of times when the area starts to kind of degrade, it'll become painful as well. So we have to just consider that it is more of an onset, and we just can't blame the cruise liner specifically on this.

But it does sound like it's a good trigger. So the next paragraph, she's talking about how she saw a PT, gave her some modifications with the pillow for sleeping, icing, stretching, and so on. And these sound like good recommendations, but they're passive to me. They're passive recommendations, which they're a good start. They're a really, really good start. Don't get me wrong. Because a lot of times you have to decrease pain in order to get the person to move better. And so sleeping with a pillow under the knee, let's just think, I'll say this after every single one. Sleeping with a pillow under your knee, does that make you move better?

No. It makes it so it's less painful when you sleep, but that's about it, right? Learning how to ice. Does that make her move better? No. It just makes it so the air is less irritated, but it doesn't stop the mechanism of why it's happening. Stretching exercises. No. It doesn't make you stronger. It doesn't make you move better. It makes areas lengthen. But who's to say the problem was lengthening in the first place? Who's saying that it was tight in the first place? Perhaps it could be that, again, that we're loading the car lid successfully because something's maybe not working. Maybe something's already too long.

Maybe a muscle attendant's just beyond its normal length and it doesn't have a normal work capacity anymore. There's a lot of reasons why I think I would add to this program. And I don't know how long she's been seeing the therapist. By the way, these recommendations given by the therapist, it can be given by a chiropractor, a PT, a physical therapist. Even a trainer sometimes can give these types of recommendations to people. So I'm not pigeonholing down that the therapist has given anything wrong. Because this is a good start. I would just add a little bit more. I would just suggest that we do a little bit more active therapy.

And, again, I don't know her complete condition, but let's just say if we found out her core is weak. So how was she able to, or her core and hip was weak. Maybe she wasn't able to offset the lateral bend and rotational forces she was getting by walking those stairs on the cruise. Okay? So we need to make sure that we optimize that. Let's just go on the route of intra-abdominal pressure, which is breathing mechanics. That's really, really important in regards to core stabilization, again. And I talk about this almost every day with patients, and I say that the core does not mean six-pack. You don't even have to be thin to have a functional core.

You can be, you know, 20 pounds overweight and have a killer, killer rigid trunk. Which, I'm going to keep saying rigid trunk because the rigidity is the important part. It's not how you look at all. So her trunk or her core's ability to resist those motions of the boat swaying back and forth is what we'd probably want to look at to see if there's a reason why this knee started getting irritated and abnormally loaded in the first place. So all the stuff you've been given so far, they're really, really good for decreasing pain, which is cool. It's totally cool because a lot of the times you might give pain medications or muscle relaxers to offset pain as well.

And these are just more natural ways or less pharmaceutical ways, which I'm always open to. But I think we have a responsibility to decrease the mechanism of how it happened. Take small doses of the poison. You have to make sure that it is resisting the movements that created it. So I think that's the major thing that's missing here. And one more thing just to hit on with this is she said she stopped working out because squatting irritates it. Now, I don't know how many times I've talked to people about this, but it's really important to realize that the squatting is not always bad. You're going to do it anyways, whether you sit down to go to the bathroom, you sit down to go eat, you're going to squat anyways.

You might as well be really, really good at it. And stopping the activity forever or for a year or two years or even like six months, I think, is just too much unless we have a real medical reason for it. And in this case, it doesn't sound like it. Now, with meniscal injuries, what it sounds like this is, usually it's not loaded excessively until beyond, I think, parallel or 90-degree squatting where basically the thighs are parallel to the ground. And I think the estimation by Warren Hammer was about 85% of the load is on the meniscus around that time. So who's to say we just can't break, go into like a quarter squat, a half squat?

I mean, are these all possible for this person? And if so, we need to be doing it because we're going to lose strength within that whole range of motion, with that whole motion. If we let her go on the mindset of squatting's bad, I'm not going to do it. So those are the major takeaways, okay? Start squatting again if it's possible. And you might have to be under the supervision of someone who knows what they're looking at. A movement therapist, which has a new term that's been coined. It could be a strength coach, a sports chiro, a PT who specializes in sports. It could be a lot of people. But they have to have a trained eye with motion and be able to cue you into the correct motion.

I've seen many people try to do it on their own. It doesn't work. I have not seen it one time. I've seen a lot of people who move well, but to correct themselves once there's an issue, I've never seen it one time. So I don't want to mislead you and think you can do it on your own. Go get some professional help. That's what's going to help you the most on this. Adding in, so the other recommendation was adding in active care, okay? Active care is going to be really important in there. And targeting the areas that are weak. And just before I go any further, I should make sure that everybody knows I'm trying to give generalized information here.

I can't legally give any direct information. Actually, this person doesn't even know that this is them for the podcast. So I won't talk to them directly about any of this stuff. But I want everyone to realize that we're just learning as a group here and just trying to break the mindset of just sit, wait, rest, let it get better, and stop squatting. Because that's a real, real danger in majority of cases. It's a good idea in some, but it's really dependent upon the pathology. But again, I can't give direct medical information. It is against the law unless I have actually examined somebody in person.

So yeah, before we go on to the next one, which is going to be shoulders, let you know that you can actually drive out here, fly out here. I can examine you, and I can manage you satellitely. So if you like what you're hearing so far, we are going to start offering that. And that is something I think will be a real big bonus because I get a lot of people who ask for help. I can't give them help unless they've been seen by me. So that is really, really going to help break the doors open in recommending what I think people should do. So next, we're going to go on to the shoulder. Okay, on to the second question here.

We have a surfing one with shoulder pain. So it says, hi, I have right shoulder pain right at the top of my shoulder as it connects to my neck. It hurts after I surf more than three times a week. The waves have been good. I want to make sure I'm not doing anything, doing any damage. We'll just get better on its own. I haven't done anything, as for therapy yet, more than taking time away from surfing and stretching my shoulder. The only thing that makes it better is not using it. Is there anything I can do to get back to surfing as much as I want to again? Thanks, bro. There really is bro right there.

Yeah, so a couple things here is, so first off, he's kind of talking about the area that's not really technically the shoulder joint. So it's actually more of the shoulder blade, it sounds like, or a muscle connecting to the shoulder blade, which really, really is important when it comes to actual shoulder rotator cuff function and obviously function of the arm when you're doing something like surfing. So I could totally understand why this is affecting his surfing, but I mean, he's surfing a bit, like five times a week. I mean, that's like a, it's like a dream right there, right? So I don't know what this guy does for work, but it sounds like he really does enjoy surfing.

So I don't know if he's getting paid for it or not, but if he is, then he might have a healthcare profession already kind of working or who can work with this. But so let's digest this down a little bit again. So it's shoulder pain, he says, but it's really, it's the shoulder blade. Okay. And if you've listened to the podcast that we had, that I had with Max Schenck, we talk about shoulder pain and kind of the pillars that we need to address before we actually address rotator cuff condition, shoulder blade conditions, and so on. And a lot of times this really starts down at the core as well as breathing patterns.

And, uh, at some point I will do a whole entire show on breathing patterns and, uh, the diaphragm, the pelvic floor, the whole core and how it functions to improve breathing. But for the most part, if you don't breathe well, we're starting to realize that your core, no matter how it looks, how shredded you are, how thin you are, it really doesn't function to the best of its ability. Now, in that, in that one, in that, in that one podcast we have with Max Schenck again, it was a pillar or sorry, it was a pyramid we had. So at the top was the glenohumeral joint, which is the actual rotator cuff or ball and socket, which is actually what we call the shoulder joint proper.

It's not really, it's not really what he's talking about with the shoulder here. Next, we have the shoulder blade, which is just below it. Below that are cervical spine or neck, as well as mid-back or thoracic spine functionality or motion. So we have to make sure that they work really well before we can even address the shoulder and the shoulder blade. But before that, again, is the core and breathing and so on. So I guess what I'm looking at here is do we need to make sure that he has a properly functioning neck and mid-back and that he can stabilize his core if he's going to get this to go away at all.

I guess the question I have, again, playing devil's advocate is it looks like it's his right shoulder. I don't think it's the volume of his surfing because it sounds like unless he's only using his right arm, he's got to use his left too, right? So there's some type of motion, some type of habit, or some type of way he's using his body that's making his right shoulder blade work more. Now, most of you might think, well, we can just massage this thing out, get it done, that's it, we're done for the day, right? No, I mean, we have to consider why it's getting tight in the first place, okay? Tightness can be from overuse conditions, such as, again, making it work harder than it's supposed to.

Or, in the case of this area right here, we can have the nerves of the neck being affected, creating increased tone or increased sensation of tightness in that area. So it might not actually be actually shortened or tight, okay? It might not be overused. It might just be that the nerves are being irritated enough, and it doesn't have to take a lot. It could just be that they're irritated enough to create an increased tone. And this is why we look at the shoulder in that pyramid formation again, is because if we don't address the stuff like the neurological conditions first, then we're just going to focus our attention directly to the shoulder blade and start beating the heck out of the muscle, and then do a bunch of isolated treatments and therapies for that area, and it's probably not going to go away.

It's going to be extremely, extremely frustrating. And this is something that is really common for people to do. They grab a foam roller, they grab a ball, and they start beating the heck out of the area, and it works sometimes, because sometimes that's the problem. Other times, it's not the problem, and it can be extremely frustrating when this thing is not going away again. So, his next question was, is he doing any damage? And, I mean, currently probably not, you know, realistically. It sounds like it's early on. It sounds like he hasn't had it before. I mean, a lot of times these things are just mainly wake-up calls to biomechanical issues or other types of issues in the body, and they don't have to be extremely serious.

It's not like I'm saying this is like a cancer or a tumor or some other type of cyst in the area, which is, you know, maybe like a surgical correction or anything like that, and it might not even take, it's probably not going to take that much rehab or therapy. But the longer this thing goes on, I mean, I think the estimate is roughly, I'd have to find this article, but I remember one research article was talking about the rotator cuff conditions, rotator cuff tears, majority of the time, a strong majority, I think they had around 80-90%, have some type of correlated shoulder blade dysfunction, so the shoulder blade isn't working well.

Did they go further on down the chain to be able to check the neck, the mid-back, and the core? I didn't see anything on the study that made me believe so, but I don't see how the shoulder blade could work without actually having those other things in place. So, again, going back to the question, is he doing any damage right now, immediately, today? Probably not. Five years? Probably. I mean, probably, most definitely. One year? Probably. You know, if you were listening to, we did a podcast with Dr. Robert Silverman, it was on nutrition and sports injuries, I believe it was in the 40s-ish, we were talking about osteoarthritis or arthritis formation, and osteoarthritis is, it was considered in the past as like a kind of wear and tear, inherited, just unlucky type of like arthritis.

Like, it just came, and it's funny, when people tend to get it, they're just very, you know, like, it's arthritis, it's just coming on, it's like kind of that whole excuse where like, I'm old, you know, this activity is too, it's too much for me at this age, and so on. I mean, what do they have it in like, God, what was that, Die Hard, what was it, Murtaugh? You know, he's like, I'm getting too old for this, you know, like, it was kind of like one of those kind of things. So, we talked about in that podcast that it's actually chronic inflammation, a lot of times it will increase the osteoblastic activity or make it so the bones start to react and start to grow, which mainly, I mean, it doesn't grow in a good sense in this, it grows all these little spurs sometimes, it degenerates tendons, and that's where you get all these degenerative types of conditions, they call them, they call it DJD, or degenerative joint disease, in the back they call it degenerative disc disease.

These things, I wouldn't, don't consider them diseases, they're progressions of things happening, which you could have checked out, you could have done something about before, and his shoulder, in the case of his shoulder right now, this is the progression. If you let it sit there, and even if pain goes away, if he lets the dysfunction sit there, it's going to develop some type of cuff tear, it's going to develop some type of arthritic condition. And, you know, I'm never to the point where I would ever tell him when I told you so, but, I mean, you reap what you sow here, really. I mean, you, if you take about, if you take care of it now, you'll probably have a healthier joint later.

Plain and simple. You have to improve the mechanics of it. You can't just assume you're going to drive, say, your car into the ground, and then think, well, I didn't get any money out of it at the end, you know? How come it didn't get me to, you know, 300,000 miles? You know, because you didn't take care of it. That's the reason why. You weren't changing the oil. You didn't change the tires. You didn't do the alignment, you know? Your dashboard got cracked because you didn't put armor all on it. That's just how it is. So, going a little bit further here, so he said he didn't do any therapy for it yet.

He's just taking time away and stretching. So, it sounds like he's doing more of, like, the, I call it the, it would be, like, the risopros, resting, ice, heat, compression. Like, those are more of, like, again, he didn't say he's doing all those, but kind of like the mindset in the past now, and we're not really there anymore, although everybody seems like they default to that first until they get talked out of it. So, that resting, do nothing, stretch it, passive therapy, we call it, or just disuse is usually the first knee-jerk reaction. I don't think it's the way we should go with this, and oftentimes, when we stabilize the shoulder, it gets much better.

And if you do nothing for it, then it's just going to sit there and get weaker and weaker and weaker. So, I'm actually going to do a podcast sometime with Dr. Richard Hansen, actually. We're going to be talking about running injuries and return to play with running injuries. It's going to be a great one, and he's mainly going to be talking about lower extremity conditions and kind of about keeping some of the miles on. And at least with lower extremity conditions, it's a little bit easier to understand because you do have to walk and run and so on. With surfing, I mean, we're not walking on our hands, but, I mean, we're still using them.

Just the whole concept of, we're going to be talking about collagen remodeling. Collagen is a protein in the area that, I mean, it makes up tendons and muscles. It's just very prevalent in the area. So, a lot of times when you have some damage, it needs to remodel itself. But it actually is stimulated with mechanical loading at some point. So, if you take all the activity away, it's not going to remodel as well as it could be if you put some type of stimulus on it. So, that's why I don't really love the rest approach anymore. I mean, there's a time and place sometimes for it, and I do recommend it sometimes.

But for the most part, it's not really any longer than like two or three days. And sometimes it's kind of like more for just the person's, their psychology, their mind. You know, give them a little bit of time to digest and think about all the things that are happening. So, because it's shocking when you get an injury, and I've been there too. But when you really sit back and you get a whiteboard, get a piece of paper, and you start realizing the things that you should be doing during certain time frames of the injury, then you realize that resting is really not top of the list. I mean, you could do it.

A lot of people do it. A lot of times their pain goes away, but it doesn't make them move any better. Okay, I'll say that one more time because, again, rest doesn't make you function better. It can take pain away, but realistically, with injuries, overuse injuries especially, pain's not the thing we're really looking to address. And I know it's a really, really important trigger for, or motivating factor for patients and athletes, but it's not really that important in regards to how you function. You know, we're tuning up a sports car here. Like, we're not, we don't care about, we're not just taking it to the point where, like, we're getting rid of a squeak.

We are, or taking the, so the dashboard lights basically come on, kind of, like, turn off. We're going to optimize it the best we can. And whether you're an athlete, whether you're a weekend warrior, you still need your body to function well. So, in regards to the shoulder, don't think about pain with this, bro. Okay? Is there anything I can do to get back to surfing as much as I want to again? So, that was the last question. I mean, yeah, you, again, you can keep a, usually keep a base on. Again, I guess I should default back again. This is not, I don't want to say I'm giving pertinent medical information here or specific stuff because I can't, I didn't see this person yet.

So, if you are listening out there, you need to go get examined, by the way. Don't take this advice. This is generally speaking because I don't know your exact case. But, for the most part, a lot of times you keep some mileage on, keep some load on, you know, and maybe this means getting out there and sponging or going bodyboarding, you know. Maybe it means swimming. Maybe you're not surfing as much. Maybe you're longboarding, you know. Like, there's different things to do. And if we scale it back and it'll keep some sanity still if you can still be out there, you know, getting some sun, catching waves and just kind of, you know, living.

So, I think that's an important thing to realize, again, that a lot of times we are rehabbing the person in the brain, not just the injury. So, a lot of times with a condition like this, you'll get back to surfing pretty quickly. But, for the most part, do not forget about the fact that it's not the pain that's the issue, it's the mechanics and how it's happening. So, that's kind of it on the shoulder there. I will go more into shoulder on some other podcasts in isolation than I have already. There's a lot to talk about with the shoulder. And if you actually haven't looked on my website yet, I wrote an entire article on rotator cuff tears and sick scapula.

Both conditions are ones that are really prevalent. So, go on there. Go on to p2sportscare.com slash. Actually, there's no slash on that one. It's just go to the main one. And it's going to be self-education or learn about your injury. And then there's going to be one on rotator cuffs, which is on the pitcher one. Or there's sick scapula, which is one of the buttons at the bottom. So, that's kind of an isolated one on your own. But next, I'm going to go into the neck. And this is from someone who was doing crossfitting. Now, this one, I'll just read it out to you. But when we go through it, I want you to realize that just like the last one with the shoulder, looking at the neck is really important because we need to clear out a bunch of neurological possible sensations, nerve compressions.

You could have spinal fractures and so on. But when the neck is being irritated, it can create a lot of referred pain, we call it. So, it can go down to the shoulder. It can go to the elbow, the hand, the arm. It can even go down to like the mid-back or on the periscapular area or around the shoulder blade, we say. So, before we even jump into this case, I just want you to remember that neck conditions are not specific only to the neck. Okay. The spine areas, especially like low backs, I know a lot of people can relate to sciatica a lot. But everybody kind of knows that when something goes down to your foot and your back hurts and it shoots down your leg, you kind of ignore the leg and the foot conditions.

You just go up and address the back. And the same thing happens with the neck here. So, let's just read it. Okay. So, hi. I've been crossfitting for years and recently I started developing pain in the back of my neck after a wad that included handstand push-ups and cleans as the major mode. It started to hurt about an hour after the workout. Pain goes into my shoulder blade, the neck, down the mid-back or down to the middle of the back. Nothing seems to make it better. I've been taking Advil and icing for about a week now. What should I do? What could it be? Okay. So, just like I said before, we have the shoulder blade, we have the neck, and then we have kind of the middle of the back.

Okay. So, there's a lot going on here. She didn't mention anything about headaches. I have no idea where the neck actually is because there's a couple sections in there. There's the high ones, there's the mid ones, and there's the low ones. So, we can't really tell here. But the first thing that I would screen out on this person already, since I don't know anything about how old they are, I don't know anything about their past workout history before crossfitting, I don't know how healthy they are with eating, I want to check, I mean, I do, we do know that she's a female, because I can tell by the name.

But I would check to make sure there's no fracture. And I'll tell you the reasons why. It's because she was doing handstand push-ups, and the cleans are, it might create a different type of neck pain. But the handstand push-ups, I mean, I've actually met a few people before that they, I didn't think they thought much of it, but they basically, so handstand push-ups, if you don't know what they are, you're basically in a handstand, you're against the wall, and you're pressing up into a full handstand from an elbows-bent handstand. So, you're basically just working out your arms and shoulders in this.

So, but the thing is, you get really tired, and I've done these myself before, and I haven't had any major issues, but one of the options we do have is to use a, what is it, an ab mat. You can use an ab mat or a pad on your head to make sure that you're not really smashing your head against the ground, since a lot of the gym floorings are like a rubber type of flooring, which is good for plyometrics and jumping and dropping weights and so on, but definitely not great to smash your head against. So, it, I didn't watch her do it. She didn't say if she had a pop or a snap. It started hurting about an hour after the workout.

But for all we know, too, I mean, we don't know how strong she is. We don't know the quality of motion. We don't know if she's been eating well, insinuating that possibly she had, maybe she had low bone density. I don't know how old she is again. If she's, if she's older, like, let's just say 45-ish. Not to say it's super old, but it's old enough to have signs of osteopenia or osteoporosis, so there's possible bone thinning already. And she said she's been crossfitting for a few years or lifting for a few years, for those of you who don't know. Maybe she's been going once a week. We have no idea.

So, I don't even know her physical capabilities on this. But if she did have, if she is, you know, 40, 45, 50, maybe she has been eating less because she's trying to lose weight, which is really common with female athletes, especially in college. I think they estimate that, and don't pin me down on this one because I'm pulling this one off the top of my head that I heard at a seminar, which had a good reference for it. But I want to say it was something like over 50% of female athletes in college have eating disorders, or we call it female athletic triad, or FAT. So, basically what happens is they end up getting bone injuries.

They get lots of tendon injuries because their bones are getting depleted of the nutrients because they're not eating enough. They don't have enough calories coming in and enough quality food. And it happens a lot with people in sports, especially distance sports, cross-country, track and field. And these are ones where I think it's even higher a percentage, mainly because they're running a ton of miles, and there might be issues with body image. So, there's a lot of energy expenditure, but the food's not getting in. So, we don't know if this person's been trying to drop weight quickly or not, or if that's even on the radar.

I mean, shoot, we don't even know when her last menstruation is. So, there's a possibility that maybe she's in there. We don't know. But either way, you have to make sure to rule out a fracture in this because there's a possibility that she just kind of smashed her head against the ground. It's called axial compression. She would basically just go top of the head straight on the ground, and the rest of the body kind of caves on top of it there and just bust a vertebra. So, and that would create neck pain, even small compression factors. It doesn't have to completely explode. It just crushes, you know.

I mean, I've heard of people getting compression factors by stepping off curbs if they have low bone density. So, it doesn't take much if your body is not, if it doesn't have the right qualities to it, you know. But it doesn't mean you can't get it back. So, the first thing I would say with this person, again, is we need to make sure to get an x-ray to rule out a possible fracture. And it doesn't matter what the symptoms are at all on this. If it looks like a possible fracture, we have to rule out a fracture. And this is one of the times that, again, I would use an x-ray, at least at the start.

But the problem with x-ray is it only shows what we call cortical fractures and alignment, really. So, what that means is if we, let's just say if we had, what's a good example? I usually use a piece of drywall because I'm looking at one right now. So, today I took a hatchet and I just absolutely just banged it against the wall and I have a slice in the wall. And you can see the insides of the wall, but you see definitely the divot in there. So, that's an example of something that would be shown on an x-ray. So, the outer cortex or the surface of the bone has been compromised, which would basically show that line or lucency in the actual bone.

But if, I mean, with x-rays, we can't really see inside extremely well. I mean, you can see some. Don't get me wrong. You can see some. But there's the possibility that the insides of the wall or insides of the bone have been crushed. And the insides of a bone, it kind of looks like a sponge or almost like a loofah, I guess. I'm thinking about a sea sponge, which, I don't know. So, if you've gotten actually, if you've gotten an actual natural loofah, the natural loofahs actually kind of look like the insides of bone. They're called trabeculae. And you can just crush a handful of those, you know.

And what you'll find is bone marrow edema with on an MRI. But you won't see it on x-ray always. And if you don't know already that, so x-rays are, I think the estimation is roughly about, so osteopenia or thinning of the bone within the spine. You only see it thinned when it's about halfway gone already. So, if you have even a small, like, crush fracture like this, then I think you want to get an MRI to rule it out. Plus, you can see the nerves around the area, too, since it looks like she's having shoulder pain and stuff down the back. So, you have to make sure that those aren't just muscular injuries, right?

Just kind of how we talked about with the shoulder. We could have referred pain from the neck creating those things. And if it is, then we need to dress the neck and leave all the other stuff out of it. You know, but if it's actually that, say, we tore a muscle there, which is highly unlikely in this case, then we need to address the muscle itself. So, it changes the treatment plan a little bit. So, she says nothing seems to make it better. She's taking Advil and she's icing. It's been about a week now. I mean, I think she should go see somebody realistically. You know, like, this is one of those things where if you get an image done, it changes the course of action significantly.

And also, too, on the patient side, like, I mean, I had a patient recently that we looked at her knee. I mean, she basically, she was cycling. You know, she was doing, God, how many miles was she doing? I think she did 300 miles in about three days, four days, I think. So, it was a fair amount. But it was a significant enough jump to where, I mean, she's never done that amount before, but she's done maybe about half the volume in that amount of time before. So, it usually jumps like that. Like, we, there's always a possibility of, like, bony insufficiency. And basically, she ended up having a fracture on her kneecap.

And it was really small, but it was there. And it was frustrating to her because she couldn't bend her knee at all. She thought it was maybe, like, the meniscus or the cartilage in there. She thought maybe it was a tendon, you know. Like, so, just the uncertainty that she had, it was really frustrating to her since she's a really active person. And she's like, well, when can I start biking again? When can I start squatting? When can I start lifting? I'm like, well, you can't even bend your knee right now without pain. Like, we can't squat yet. I said, but what we can do is we can take, actually, we took an ultrasound on that.

And we saw irritation to the surface of the bone and lots of vessels going into the area, which insinuated a possible fracture. So, at that point, I mean, we could take an x-ray. We could take an MRI. But for the most part, we were pretty sure that it was a fracture. So, we set a reasonable timeline. And from that point, it really improves, I don't want to say mental well-being, but it gives the person a sense of control, which is, I think, really important in regards to patient compliance and also, too, with stress. So, stress basically stimulates the sympathetic nervous system, and we call that fight-or-flight mechanism.

So, I just kind of want them to relax and just know that things are going to get better, and they will, but there's nothing they could do different, at least, say, with this knee injury we're talking about. There's nothing she could do at that period of time to make it any better. Okay, we're 99% sure it was a fracture. So, she can do core stuff. She can do hip stuff. She can do a bunch of other things. But she just couldn't do those other couple things. So, and in the end of it all, it really, really got better in a good amount of time that was consistent with a bone injury. So, it made complete sense.

So, I know I tangented there a little bit, but so, with this person that's doing CrossFit, I think we need to confirm and make sure there's a solid plan of attack, since probably what this person is going to do is rest it for a little bit and test it again. And when they test it again, it might just get more irritated. Then she'll take a week off, and then she'll test it again. I mean, it's like a, it's a vicious cycle, and it's extremely frustrating, and it doesn't help out the injury site. It doesn't help out the athlete. It doesn't help anybody out. So, a lot of times you get an image just to confirm or unconfirm that.

And if it's unconfirmed, by all means, like if you're cleared by your doc or your sports medicine person to be able to test it again, you know, go ahead. But it's all about risk-reward in this. And we know that with a fracture, you're not going to be tested at all. You shouldn't be, you know, until that fracture heals up. So, it sets reasonable expectations. So, she asks, what should I do? What could I be? What could it be? I think we kind of already answered that, so I think we can move on from this one right here, and we'll go on to the last one, which is a knee with a golfer. And if you have not already listened to a knee podcast, I've already done a couple extensive ones, and it seems like some common topics that we end up going into here.

Our knees, shoulders, and hips. I mean, those are all really fun joints to work with. So, there is a podcast specifically on knees. It's called, I think it's called Knees, Everything You Need to Know Before Rehab. Start there. And the next one is by Davis Koh. And it's, we call it Looking for Snipers. So, that one's going to be really important for anyone who's got knee conditions there. And you can find that on p2sportscare.com slash podcast. So, here we go with the knee condition. Hi, I've been golfing for, or sorry, hi, I've been golfing and spinning for years now. Sorry about that. Like I said, I hate this popcorn game.

I spin about three times a week for an hour and golf two times a week. Last week, my knee became really painful after extending it fully and standing at my job. It has started to click and feel tight as well. I'm freaking out. I've been able, I haven't been able to walk, let alone spin or golf. I love to be active and I'm concerned I will gain weight during this injury since I can't do spin. I'm 45 years old and my metabolism isn't what it used to be. What could it be? I haven't seen a sports medicine doc yet, but I have an appointment this week. Any suggestions will help. So, funny thing is probably by the time, if she's listening to this, she's probably already had that eval.

So, it'd be interesting to see if I was right in this one, but we'll see. So, knees. Okay, first off with knees, similar to shoulders, we have to have that pyramid, okay? So, the bottom of the pyramid is we have core and breathing. Then the next up is we have thoracic spine and lumbar spine function or mobility. Next we have is pelvis and hip function. And then we have the actual knee. I mean, arguably, we can say, yeah, the ankle's in there too. And it'll probably be in the pillar just below the actual knee joint. And I'm still working on improving that pyramid there. So, if you are a healthcare provider, then I'd love suggestions of how to clean that pyramid up a little bit.

But for the most part, we do know we have to look at the joints above and below a little bit. So, and the things that strike out to me first is that golfing, okay? Golfing is a rotational sport. Spinning, she's more of kind of hinging it there. So, that's not the highest of my concerns. But if she does have terrible extending or locking, unlocking patterns, then if she's extending fully on the pedal stroke, then I think this could be something which just kind of degrades the area, which hasn't been working well anyways. And it looks like the pain is more so when she's fully extended and it clicks and it feels tight.

So, the area I would be concerned about mainly is the meniscus. I don't even see, sorry, I'm scouring through her email right here. I don't see anything that says where, inner or outer. She just says it hurts to extend. If it was the outer side, I would say, again, the lateral meniscus, clicking, popping can be from a couple things, by the way. So, clicking and popping, especially in the knee, we could have fluid moving around, okay? It's kind of like, I think about a water weenie or a water balloon. When you squeeze it, it just kind of spurts out towards the other side, okay? And sometimes this can go with a, right, a little pop noise because it's shooting out to the other side.

So, that's fluid in the area or fluid moving could be from the joint capsule that's being inflated due to some type of internal knee injury or chondromalacea patella, meniscal tear, ACL injury, PCL injury, even some of the MCL, LCO, which are the lateral collateral ligaments or the medial collateral ligaments. So, there's a couple things in there which can create those types of conditions or that type of swelling. But for the most part, when the fluid moves, it's not really, that click is not a huge major concern. A lot of times, we're looking for the underlying condition further, which is creating that thing to blow up, okay?

So, you said it feels tight. So, it makes me feel like part of it is that. But, again, there is a possibility that the meniscus, especially if it's locking that and you can't get it out of position to unlock it, then we have the possibility where there's a meniscal tear or a section of the meniscus or carlage of the knee, one carlage anyways, that is catching, okay? So, the catching will make it so you won't want to lock and unlock the knee. It'll feel like it's stuck in one spot. But it sounds like what you're talking about is it hurts when it's fully extended. And, I mean, I would check the popliteus muscle on the backside outer area of the knee, which actually goes and attaches to the outer meniscus, so the lateral meniscus.

Because standing and locking, it really, it affects the screw-hole mechanism, what we call the knee, which is, again, the popliteus will start to position the lateral meniscus. And also, even though the femur or the thigh bone and the tibia there are kind of like, they're stacked on each other, this muscle helps kind of like lock it into position so we can drive and produce force through the leg without it buckling. So, I would check that, but really, I mean, there's a, I mean, let's just say we get an image on this. The x-ray is probably negative because, or it's relatively negative in regards to fractures, because there was no trauma.

There's no, I mean, I don't see anything in what you said, which makes me think that there's a fracture. Maybe there's old fractures, but it doesn't, I don't see anything that means new fracture. If there was a new fracture, then I think we have a bigger fist to fry, then we have to figure out why the bone's so darn weak, you know, and that could be from, you know, a bony cyst or a soap bubbly lesion. It could be a lot of reasons, so I think that's a bigger concern there. But an MRI, I bet it will show, you know, fluid within the knee. I bet it will show maybe a pop or a popliteal cyst, maybe.

It might show a lateral or medial meniscus tear or a small one, but this could be like that already. And I think I should probably talk about that actually before we go on, is that MRI and x-ray findings aren't always the issue. They're not always the pain generator. And this person, I mean, it sounds like a week prior to this, she was really active. She could have easily had any findings that she had in the, excuse me, gassy there, burping. She could have had any of those findings on the MRI, such as a meniscal tear, you know, like an ACL strain, fluid within the knee. She could have had all of it.

She could have had all of it before, and the knee didn't even hurt at all. And actually, if you watch, there was a video that I did with Mike Jabilon on my knee, because we were talking about ultrasound for the knee. He looks in there, and he found a bunch of fluid, a drainable amount of fluid, that a lot of times they do with painful knees. And it was 200 cc's, I guess he was estimating. Mine didn't hurt at all. So it's an incidental finding. It was there already, but if my knee hurt today, then it's still there. They might say, oh, well, let's strain that fluid out right there. So if she did a MRI of this knee, then I think there's a possibility that they'd find something.

But it doesn't mean it's the issue. It doesn't mean it's the main issue we need to address. So I think what I would do with this person, because if she went in and got the image, she might say, oh, well, there's a lateral meniscus tear. I think we need to address it. We need to have surgery on it, or whatever the heck. You know, like a lot of times people focus on that thing as being the problem. But really, the problem is how you move. And so I would first have her listen to my other podcasts, honestly. And I've done this to other people that have come to my office, too. One lady in particular, she's come in and out a couple times over the years with random problems.

And, you know, she came up with a knee condition this time, and I was straight with her. I just tell her, look, I'm not even going to work with you. I mean, she's a good friend now, so I can be very blunt. I said, I'm not even going to work with you until you listen to this podcast and this other podcast. Because really, the understanding of working above and below and working these other areas is what she's going to need, even if there's a positive MRI finding. So with this person, I would want to educate her first, the very first, because she has to buy in. She has to buy into the idea that the rotation from golf possibly could have been an irritant, but she has to get her body to get better at rotating, okay?

One test that we do for meniscal injuries is called Thessaly's test, which is basically rotating, okay? The knee doesn't like to rotate. The meniscus injuries usually flare up with even the amount of stress of being in your bed, and you catch your foot on a blanket, and it turns your knee. It twists it a little bit. It's irritating, okay? So we've got to get the body to function better with rotation in your sport. So in this case, it's going to be golf. So I would have her listen to those podcasts first. And if you don't know, if you haven't listened to those yet, again, they're probably around the early 30s, I believe.

The first one, the knee one, is extremely boring, but you should listen to it. If you go halfway through, you're going to find out that I'm talking about mechanics. It's a little bit more interesting. And the one where we have with Davis Co. is a lot more interesting, but I would probably start there with her. I'll put these all in the show notes, by the way, so you guys can find them. But for the most part, we've got to buy her in with this. And yes, I would probably have her do some treatments locally to the knee because she hasn't seen a doc yet, so she doesn't know what they're going to do.

But I don't think I would do anything to decrease the pain, honestly, in regards to an injection or a surgical procedure if there was no urgency for it. Okay, let me start with that because I don't know exactly what they're going to find on the images because some of the things like bucket handle tears in the meniscus, I mean, they're usually ones that are going to end up needing something done. You know, but for the most part, I would say at least 9 out of 10 of them, I mean, you've got to earn your surgery on this. You know, you have to prove that your body is going to tolerate that rotation and that lateral bend in the knee for your sport.

And repairing it isn't going to make you function better. It just makes it so you can get that locking to stop, at least if that was what was happening. So I would probably, at the very most, in regards to pain on her, is I would probably do some tissue work around the knee because a lot of times this makes it less painful a little bit, but they don't usually feel that it's the end-all fix, like if they had a successful injection within the knee. So, I mean, I've talked to many people. I mean, there's a lady that came in a couple weeks ago that she was dead set on. And she's like, why don't we just inject it?

And I said, why? And she's like, well, because I did one two years ago on another joint, and it hasn't hurt since. You know, and I was like, well, I don't think you really want to do that. I don't think that that shouldn't be your first thing. She's like, oh, I just want the pain to go away. So sometimes when you take this pain away, it's the worst thing you could possibly do to somebody, I think, in regards to improving how they're going to be in the long term, okay? So I would probably give a little bit of pain relief in regards to tissue work, and that could be in the form of ART. It could be grassed in.

It could be foam rolling. It could be adjustments. It could be anything. It could be acupuncture. Whatever works. And I'm not going to – I mean, I'm sorry if I missed some treatments in there. But whatever works, we need to get them to move better to rehab them, and that's kind of it, okay? The more we get them to – the better we get them to move, the better this knee is going to fare in the long run because eventually over time, this thing probably will. I mean, she's 45 already. She's probably going to have arthritis set in, and if it gets too far, then they're going to replace the whole knee, okay?

So I guess I kind of tangented a little bit there on that one, but I guess I should bring it back. And she did bring in one thing in here, which is a little bit of a mental game sometimes with people. So she said, I love to be active, and I'm concerned I'll gain weight since she's 45 and her metabolism is slowing. So I always tell people that abs are made in the kitchen, glutes are made in the gym, okay? I have no problem with either of those mentalities with this condition. She could eat cleaner, probably. I mean, most people can. I mean, even if you eat really, really well, it doesn't mean you can't clean it up.

I mean, if you're going to get shredded and lose some weight, realistically, you can't outwork out a bad diet. So we need to make sure that she's really dialing in her nutrition at this point, and if she can't, then she needs to work with someone for it because if that is the main thing that's going to get her to feel like she's able to have a little bit of extra time to rehab this area, then that's what we need to do because we're buying ourselves time in this regard because if she feels like she's gaining weight, she's going to jump on that spin bike and just hammer it out, and she might not fare well with it if she hasn't been doing her rehab.

Now, again, when I said the glutes are made in the gym, I'm all about with knees, we work glute stuff, we work hip stuff, we work core, we work ankle. So a lot of times you can get away with doing like an RDL or a barbell hip thruster or clamshells or core work. I mean, there's tons of stuff you can do. So with knees, I guess I should almost make a banner with this, I feel like. If you have a knee condition, you're worried about gaining weight, abs are made in the kitchen, glutes are made in the gym, so hammer at it, you know, like for the most of the time, all that stuff's going to be safe and it's going to be better in the long run for this knee anyway.

So I think, I mean, so these are just example of a few questions that I got here. So we got a knee, we got a shoulder, a neck, and another knee. So if you do have conditions, just email me, you know, like I like answering these things, honestly, I really do. And I like having experts on too. So if you have an expert that you want me to interview, I'd love to. I mean, I learn every time. I mean, I feel very grateful that I can do this podcast and learn new things from experts all the time without actually having to go out of town and go to a seminar. And I know a lot of these guys don't put on seminars.

They're just in their clinic learning new stuff. They might be in the lab learning stuff. So it's not necessarily shared all the time. So I hope you guys are learning stuff from this podcast as well. So I, I mean, I would venture to say that, I mean, like I did take a lot of seminars back in the past, but I mean, this year I, I mean, I have to take some for continuing education, but really I, I would rather just interview each person for an hour. I mean, I feel like I learned more from that, from that. And I get to ask pertinent questions and record it all and hear it forever. Then, then I, I mean, I feel like, I feel like I get more than actually go into the seminar itself.

So, um, and I think we're, we're spending more information in the long run. I realize I'm not getting technique based stuff, but sometimes, um, knowing where to go is, is much more important. So, um, if you guys have, have not been to the website already, so it's p2sportscare.com. Um, all the podcasts are on slash podcast. Um, and if you haven't subscribed on iTunes, please do. Um, it really, uh, is that easy and it'll shoot it all straight to your phone. Uh, if you haven't reviewed yet on iTunes, please do it. Um, it really helps me get better content out. Just go on there and tell me which podcasts were your favorite, which ones you didn't like, which ones I should start doing.

You know, I only do this for me to learn, but also to understand what everybody wants to hear. Also to hear about what misconceptions there are, since a lot of times we have to really break those barriers down in regards to, uh, you might have poor education on certain topics, which, I mean, my job is to challenge those, uh, false ideas and give you research and other experts who will educate you and tell you why those are false assumptions. And, and that's half the battle on these sports injury conditions is we have to make sure that we have the right mindset and we're going the right direction, not just doing random rehab and treatments in the hopes it'll get better.

I mean, there's a standard process here. We just have to make sure that we're going down the right path. And don't get me wrong. There's, there's different ways to skin a cat on this, but for the most part, we, we have to go in the right, the same direction. So, uh, again, p2sportscare.com and read all the articles on there. I spent a ton of time making them and, uh, I will, I guess, speak with you guys next time. And, uh, yeah, uh, I think I'm out. I'll talk to you guys soon. Bye.