Episode 66: Exploring Sports Injuries
On this weeks episode we are exploring common sports injuries and prevention techniques with Dr. Jason Ahlan, ND.
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[01:28] Cassy Price: Hello. Thanks for tuning into Supplementing Health. I would like to welcome Jason Ahlan, naturopathic doctor. Jason is one the founders of Paradigm Health Group here in Calgary. He is an athlete and an outdoorsman which has led to his passion in sports medicine and pain management. He utilizes this passion in his practice today and will be discussing the ins and outs of common sports injuries. Thanks for joining me Jason.
[01:50] Dr. Jason Ahlan: Thanks very much Cassy.
[01:51] Cassy Price: So, what are some of the most common injuries that you see in your practice?
[01:55] Dr. Jason Ahlan: That is a great question. I generally see all manners of injuries, but I would say that the four most common would be knee injuries, lower back injuries, shoulder injuries and ankle injuries. Knee injuries definitely with repetitive use from running, cycling, Patellofemoral Syndrome and those kinds of things and then also knee injuries that come from contact force like a tackle in the football for example. I see a lot of lower back injuries, chronic pain with flexion and extension and sometimes when there is discogenic pain when there is a disc involved or when there is neuropathic pain from nerve injuries. Shoulder pain especially the supraspinatus muscle and tendon, the subacromial-subdeltoid bursitis and instability in the shoulder. Then a lot of ankle injuries. There is a lot of ligaments in that lower ankle. The ATFL which is the anterior talofibular ligament or the post talofibular ligament, the calcaneofibular ligament, all of these fancy names for ligaments that stabilize your ankle when for example in trail runners when they invert their ankle sometimes, they will sprain those ligaments.
[03:10] Cassy Price: Right. Okay, so sprains are a common injury that can result from a multitude of sports not just running but soccer or in some people’s cases it can happen just walking along if you roll your ankle or something like that. What are the tell-tale signs of a sprain?
[03:26] Dr. Jason Ahlan: Totally. So, the classic definition of a sprain is a wrench or a twist in the ligament. Usually, it is violent. So, it causes pain and swelling but it is not dislocation. If you have a sprain usually the doctor will grade that sprain. A grade one is stretching of that ligament or very mild tear. There is usually very little or no instability in that joint. A grade two is a more serious injury. It is usually still an incomplete tear, there is a little bit of looseness in that joint and a grade three is a completely torn or ruptured ligament. In medicine we often think or quote that a ligament will tear when it is stretched more than 6% of that original or normal length. So, to answer your question Cassy, a tell tail sign of a sprain would be pain, swelling, bruising and a limited ability to move that joint.
[04:29] Cassy Price: So, if a sprain is left untreated, are there adverse effects that can be the result other than just looseness in the joint?
[04:36] Dr. Jason Ahlan: Yeah, that is a great question. Let me use an example of a sprained ankle. I think a lot of times when we think about a sprain we think about an ankle. Statistically about 80% of sprains in the ankle are in the lower ankle ligaments, so what can happen is that if you do sprain the ligaments in the ankle and we pass that golden rule of 6% it could turn into a serious instability if left untreated. When you leave torn or stretched ligaments to heal on their own, they can fuse haphazardly and form weak and inflexible scar tissue so because of that your range of motion might suffer, you might have difficulty working and then from there potentially you could run higher risk of adverse effects like arthritis or degenerative joint disease in the case of your ankle. If it is another area in your body, it could be degenerative disc disease if it is in the spine, it could involve nerve pain and neuralgias too. I think it is also important to say with ankles that we want to rule of fractures because that is one thing that can be overlooked. There is one thing that is called an Ottawa Ankle Rule and it helps to determine if the patient should be offered an x-ray to rule out bone fractures. Then I know I talked a lot about ankles there, but the same thing could happen with sprains in the knee for example in some of the collateral ligaments or the cruciate ligaments. It could happen in the spine, say for example the neck or the cervical spine with whiplash injuries. It could happen in the SI joint. There are so many joints that have ligaments that stabilize them and become sprained.
[06:19] Cassy Price: So, if you get a sprain is wrapping the affected joint or area enough to help it heal properly or is other treatments such as physio and things like that required as well?
[06:30] Dr. Jason Ahlan: Yeah, that is a good question. For sure when it is an acute sprain I do think wrapping helps because the last things that you want to do is cause further injury to that area. We often think that if the area isn’t healed completely and you reinjure in it will delay that healing quite a bit so wrapping protects that joint in the acute setting. In general, we also don’t want to promote wrapping indefinitely because your joint needs that stimulus to get stronger and a wrapping can sometimes give you that false stability that means that the patient will always have to wrap in these areas of high injury potential. I think physio is a good option because a lot of times when you do have a sprain there is a weakness in some of the associated areas, some of the other ligaments or tendons, there could be higher risk for that joint degenerating physiotherapy, chiropractic, naturopathic treatments can all help.
[07:34] Cassy Price: Once you have had an injury to a particular joint or ligament on the body does it then increase its likelihood to be reinjured down the road?
[07:44] Dr. Jason Ahlan: Great question Cassy. It depends. I think many factors are involved. I think some cases complete healing, if you let the area completely heal it will drastically minimize your chance of recurring that injury again or subsequent injuries happening. So, that is always the aim of care. In some cases, like concussions, achilleas injuries, knee injuries, sometimes if you have suffered that previous injury it does increase your chance of recurring it again. A lot of times with ligament sprains and tendon injuries, like I was mentioning, if we don’t let that area heal very well and you reinjure it again before it is healed it will take a lot longer to heal up the second time.
[08:31] Cassy Price: So, we have been talking a lot about legs and knees and ankles and what not so another injury that happens a lot when you are doing sports that require running and leg use, if you will, are shin splints. So, what causes shin splints?
[08:50] Dr. Jason Ahlan: The definition of shin splints is actually technically called medial tibial stress syndrome. The shin split is stress on that shin bone or tibia and the connective tissue that occurs in the athlete especially if there has been recent increased activity, change in training routines, intensity, and those kinds of things. What causes shin splits? Overloading those leg muscles, the tendon or the shin bone, overuse with too much activity or increase in training. It happens a lot with runners and gymnasts and dancers because it is often an activity that is pretty high impact and repetitive. We have to make sure that you rule out a stress factor. For running, if I can give a particular example, runners that increase their mileage too quickly can sometimes run higher risk of getting shin splints.
[09:51] Cassy Price: And can shin splits be healed once you have occurred them?
[09:59] Dr. Jason Ahlan: Yes. Generally, rest and ice are usually recommended. I’ll usually say that when an athlete does have shin splits to avoid overdoing it. I think for the specific example of running, choose the right shoes. I think a lot of runners are running in shoes that are just too old. A lot of manufacturers will recommend changing your shoes after five hundred kilometres. I will often recommend that runners running on consecutive days to rotate shoes to give those shoes a chance to heal between runs. There has been some research out of Harvard, a Dr. Dan Lieberman he has popularized the idea, along with the book Born to Run, to consider zero drop shoes meaning that the padding under your heel and your forefoot is very similar in stock height. That might help reduce impact from running. Then I don’t think we can forget about strength training exercise and conditioning to strengthen and stabilize those legs, the ankles, the hips and the core. Sometimes we will also recommend gate analysis just to make sure that the biomechanics of the run look good.
[11:22] Cassy Price: Can cross training help for all sports then?
[11:27] Dr. Jason Ahlan: Yeah. For sure. That has definitely been a new thing talked about lately with hockey, right? I think when you do cross train you stress different areas of your body differently and that dynamic movement helps prevent injuries, I think for runners for example cross training with cycling, cross training with swimming, even things like trail running and varying the sports I think does make you a lot stronger and can prevent injury.
[11:57] Cassy Price: Do you find there is specific sports or activities that place people at a higher risk of developing an injury?
[12:05] Dr. Jason Ahlan: In my opinion, all sports can place someone at a higher risk of injury. Most common sports right now for injury is actually basketball. Ice hockey and wrestling were actually seen as the fastest growing sport for women. Repetitive use injuries like running and cycling if we are talking about specific sports, it can expose problems with biomechanics and place that athlete at a higher rate for developing that injury. Other sports like football or rugby, impact sports, can put higher risks for concussions for those athletes or speed-based sports like skiing or mountain biking could put athletes at a higher risk for trauma. In general, sports, when I think of it is that there are intrinsic risk factors which are things like your age, your sex because there is some data that women because oestrogen may be linked to decreased pentile strength in those tendons, women may be at risk for certain injuries during her menstrual cycle. Body composition and even fitness levels. Sports also have intrinsic risk factors like human factors, teammates opponents, protective equipment is usually involved like helmets and mouth guards. Sports equipment, for example ski bindings, will release to prevent knee injuries and falls. Even the environment there is a lot of risk factors like the weather, for example, in mountaineering and then a lot of playing surfaces may increase risks for developing injury like an ultimate frisbee on grass, there is a lot of injuries in the achilleas injuries from that playing surface.
[13:54] Cassy Price: Do you find the age in which you started your preferred sport or sports impacts your likelihood of having an injury?
[14:04] Dr. Jason Ahlan: Yeah, that is a good question, Cassy. To tell the truth I don’t see that in my practice. In some ways, I think of my two kids. I have a three-and-a-half-year-old daughter and an eleven-month-old son and they are coming to do a lot more than my wife and I did at our age. Seeing patients in my practice now I think the ones that started early in some ways they are competitiveness, and their skill levels are a lot higher, and they are a lot more progressed but I am not seeing particularly more injuries. I am trying to think if there are any examples off the top of my head, but I guess if we look at ballet, for example, a sport where athletes are starting very young, we do see higher risk of wrist injuries because of the elasticity of the ligaments in the wrist. Even with runners there isn’t a lot of strong data saying that with accumulative kilometres run there is a higher risk of injuries in ligaments or tendons or even in the joint.
[15:13] Cassy Price: Okay, cool. So, then are there changes that athletes can make to their training programs to make them less susceptible to injury?
[15:21] Dr. Jason Ahlan: Yeah. That is a good question. Aside from the obvious stuff I always say do more of these things so be patient in terms of running or lifting weights. Be patient. Increase your miles slowly. Increase your weight slowly. Usually, we say the 10% rule per week is a good number so if you are increasing your mileage as you train for say a marathon, not increase your weekly mileage by more than 10% per week. Rest. I think a lot of us are jamming a lot into our day, there are certainly less hours in our day these days. Rest is so important. There was an elite athlete study that was quoted at the last Harvard Sports Medicine Course that I just did. They were giving compelling evidence that only but 3% of athletes can function at a high level with less than six hours of sleep. So, a lot of times when we ask about sleep a lot of these athletes are getting less than that and I wonder whether that is something that can be easily fixed. Strength training through a qualified physiotherapist or personal trainer. I think that can modify or help a lot of the weaknesses that can predispose us to risks for injuries. Something recently that I have been referring a lot to is mobility work and what is called CARS, controlled articular rotations, and trying to get athletes to move in different planes of motion that can help. Gone are the days where I think a strict bench press or a squat will prevent injuries. Now we are doing things at different angles and speeds and reps to try and promote strength in different ways.
[17:15] Cassy Price: And you yourself have some experience as an elite athlete with your Iron Man experience and all your mountaineering that you have done. Do you find that when you start to up your level to that elite stature you need to do more, or do you find that it is more about that rest and nourishment at that point?
[17:37] Dr. Jason Ahlan: Thanks Cassy, that is super kind of you to say. I wouldn’t say that I am elite but for many years I did love to compete in the sport of triathlon. I was honoured to represent Canada at the Age Group World Championships at the Iron Man 70.3 World Championships and the Xterra World Championships but through that it actually gave me a lot of opportunity. There is a really good sports medicine conference in Kona every year and Kona is a small island in Hawaii but hosting one of the largest triathlon events in the world sometimes over two thousand athletes. Because there are not a lot of doctors on Kona to man the medical tent, they do this amazing sports medicine conference for five days and then we’re the doctors in the medical tent for the event itself. I did that for three years. Maybe I would say, what does it mean to be elite? In some ways the recreational athletes train as much as our elite athletes and sometimes our elite athletes they actually modify their training to include more rest than our recreational athletes. Maybe the way I think about it is that performance and dedicated time might define being an elite athlete or maybe even a sponsorship. In my practice, I think in some ways being an elite athlete actually increases your risk of developing an injury because there is a lot of performance pressures but in other ways in can actually decrease your risks too because a lot of elite athletes have better access to professionals, better equipment, better coaching. There was actually a football players health study done at Harvard and they looked at the rates of injury in the NFL vs ‘ordinary black athletes’ and for example they looked at economic disparities in the treatment. I think being an elite athlete does sometimes increase but it can also decrease risks of developing certain injuries.
[19:42] Cassy Price: So, speaking of that performance pressure, what happens if an athlete tries to play through an injury? How can they know how much pain to push through vs when it is time to call it quits?
[19:54] Dr. Jason Ahlan: Yeah, that is a huge question. I think in general we think of a progression to play based mostly on patient tolerance, but I have a little bit to say on that personally. I remember the Boston Celtics; the chief medicos officer did an interview and at that time he was saying that part of what makes an athlete an athlete is the ability to play through pain. I have to disagree with that. I think data showed that at the Rio Olympics 52% of doctors admitted to giving prophylactic pain relief to their athletes along with anti-inflammatory drugs but also things like injections of ketorolac. There is actually a class action lawsuit happening right now, I think about two thousand former NFL athletes and their lawsuit is about causing drug addictions and the side effects to the kidney and the GI through playing through pain and being medicated through it. We know that retired NFL football players are four times more likely to abuse opioids. My advice is never play through a serious injury for example a stress fracture or concussion, you will never win by that. A lot of that, they say the male brain isn’t really mature until twenty-five so when we are looking at the subsection of the population especially with elite athletes there is a lot of counselling that we can give them to trust in the professionals and speak up and be careful of peer pressure. I was talking a lot about the NFL. They say that over 80% of the NFL players would rather get hit in the head than the knee. That is what Rob Oconowski said. It is an interesting subset where athletes re almost pressured to play through an injury and I think that could have some detrimental effects.
[21:55] Cassy Price: So, is there a timeframe or a window of time where an athlete should get treated for an injury? I’m sure it probably varies a little bit depending on what the type of injury is, but if an athlete doesn’t receive proper treatment within that window, does it impact their long-term outcomes?
[22:16] Dr. Jason Ahlan: Yeah. You are right. It does vary according to the treatment that therapeutic window can vary. For example, if we are talking about something like medication or ice, sometimes you want to get started with that treatment right away. Maybe the first thing is to diagnose that injury. Some will require immediate attention or treatment, like a concussion, whereas other injuries like a ligament sprain, when I was talking about the ankle injuries, you can wait a little bit longer, usually treatment starts when swelling goes down and the patient can walk without pain so maybe about two weeks after that injury. Now, waiting too long isn’t good either. If an athlete doesn’t receive proper treatment within that therapeutic window sometimes long-term outcomes could mean more injury, or it could mean the injury lasts longer or heals more poorly and potentially there is higher risk of injuring that area.
[23:19] Cassy Price: So, if an athlete suffers from a chronic condition such as chronic inflammation or maybe diabetes or something like that, does that impact their treatment and the outcomes after their injury?
[23:31] Dr. Jason Ahlan: Yeah, yes to both. Chronic inflammation, even things like heart disease, rheumatoid arthritis, autoimmune conditions, that excessive and prolonged inflammation does result in delayed healing and maybe even increased scar tissue formation. For diabetes, often one of the worries with diabetes is poor circulation or lack of blood flow, it does make it more difficult for the body to deliver growth factors, oxygen and even nutrients at injury site so then it does cause more poor healing. We know wound healing diabetics is a lot slower, sometimes these wounds don’t heal at all. With both, I usually say that knowledge is so important for chronic inflammation to make sure that the patient talks to their doctor about blood tests and things like ANA, CRP, Homocysteine, Ferritin, there are a lot of cool blood tests that can help manage that chronic inflammation. Then for diabetes, a lot of the blood sugars can be tested, Haemoglobin A1C. Then there are treatments too, right? I think for chronic inflammation we know that fish oils, curcumin, can be very helpful in managing that inflammation. For diabetes, there is a lot of good research coming out that not only exercise, which we have known for a long time, but low glycaemic index foods but there is a lot of research supporting things like intermittent fasting and supplements like magnesium and geranium and things like that.
[25:19] Cassy Price: So, you’ve mentioned a few of your treatment protocols or even the testing that helps you determine what your treatment protocols would be. Are there certain types of therapies that you use or find most effective for all athletes or are they all very much tailored to the specific sport, athlete, injury that comes up?
[25:39] Dr. Jason Ahlan: Yeah. In general, I do recommend them for everyone only because, like I was saying before, some of our recreational curlers and golfers are just as passionate about their sports as Olympic athletes. I learned early in my career that I should really try to differentiate the group in terms of their performance or their medals. So, I am a little bit biased. My practice is mostly in Calgary and focused around regenerative injection techniques. Things like prolotherapy, platelet rich plasma. I find them very effective for helping these injuries heal faster especially in that case with ligament and tendon injuries especially in conjunction also with a good chiropractor or physiotherapist. There are therapies that are kind of coming to us. When I go to these sports medicine conferences there is a lot of talk about adipose and bone marrow derived stem calls. That is an emerging treatment therapy that is being researched a lot more although in Canada that is not performed. I like using IV therapies, delivering nutrients through intravenous access. It can help. We do have to be careful of those treatment plans for elite athletes. Then something that I was mentioning before, even diagnostic testing, like you were saying blood work, just making sure that iron and vitamin b12 is checked to make sure that we are not missing anything for vegan or plant-based athletes. There are a lot of fancy tests like the Nutra valve, that is a full nutritional evaluation of vitamins and minerals. For hormones there is now genetic testing, nutrigenomic testing, that can help predict risks based on genetics and nutrition. Yeah, so, to answer your question I do think there is a lot of therapies that are effective, and I think recreational and all the way to Olympic athletes can make use of these kind of tools.
[27:57] Cassy Price: That’s awesome. It is so cool how much is actually out there and available to people nowadays compared to even ten years ago when it was still very much an emerging field. It is exciting to see the advances that are coming out now in health and wellness.
[28:15] Dr. Jason Ahlan: Yeah. I am so excited about that. I think a lot of times what spearheads a lot of this is elite and professional sport but then it does trickle down and snowball down to practices like mine where what I learn at a sports medicine conference or on a pro-team helps these weekend warriors a lot especially with sports medicine. I think because performance is so important athletes will do as much as they can to get that 3% extra in speed or heal that 3% faster. Some of that knowledge then passes down to the golfers that have a knee injury on the weekend or the trail runners who are training for their first ultra-marathon.
[29:00] Cassy Price: Fantastic. Well, this has been a great conversation. I really appreciate you taking the time to chat with me today. If our listeners want to work with you is your website the best way to get a hold of you?
[29:09] Dr. Jason Ahlan: Yeah. We are working on a new website right now but www.paradigmhealth.ca is our website. You can book, we have eight naturopathic doctors, two medical doctors and even a nurse practitioner at our clinic so we have a wide spectrum of people hoping to lend you their expertise for other matters even that are not related to sports injuries or pain management. I am on Instagram @drjasonahlan. I tend to update that a little bit more regularly with personal things I have learned. Then you can always phone the clinic or email. 403-301-7406 or firstname.lastname@example.org
[29:57] Cassy Price: Fantastic. Thank you again so much.
[29:59] Dr. Jason Ahlan: Thank you very much Cassy. Thanks for having me.
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