Wellness and Performance Medicine: Doctors Kelleher and Ahmed
Inez M. Kelleher, M.D.
Marwa Ahmed, M.D.
Medical School: Medical School: Georgetown University School of Medicine Weill Cornell Medical College in Qatar Residency: Residency: Orthopedic Surgery, Mayo Clinic Weill Cornell Medical College/Columbia University Fellowship: Fellowship: Pediatric Orthopedics, Children’s Hospital of Philadelphia Sports Medicine, Stanford University
Maximizing performance through the lifespan
Combined wellness approach optimizing nutrition and lifestyle for goal achievement
Using the latest diagnostic tools and therapies including office-based musculoskeletal ultrasound imaging, regenerative orthopedics and surgery
Genetics: sports and nutrition
More About Dr. Kelleher:
A masters track and field athlete herself, Dr. Kelleher has been using MOVE! principles for her athletic training and achievements since 2012. They include a silver medal at the National Senior Games and podium finishes at U.S.A. Track and Field National Masters championships in sprint events. She has been speaking to MOVE! groups and writing website articles about MOVE! principles since 2015. Find her articles related to musculoskeletal health and nutrition for athletes below.
Inez Kelleher on the track.....
Achilles Tendonitis....causes, treatments, nutritional suggestions (and a bone broth recipe!) by Inez Kelleher, M.D.
The phrase “Achilles heel” has mythological origins and is defined as an area of weakness in spite of overall strength, a vulnerability. The mythological character, Achilles, met his demise when a poison arrow was shot into the tendon just above his heel. The Achilles is, then, a fitting name for this tendon, the largest tendon in the body.
The Achilles attaches the calf muscle to the heel bone and provides power during the push-off phase of running and walking. Achilles tendonitis is generally an overuse injury causing tendon tenderness, swelling, and pain with activity immediately or even the day after exercising. Pain and stiffness can also occur along the tendon in the morning.
Achilles tendonitis is common in runners. It is more common as you age and men are at higher risk for it than women. Injuries are related to increasing distance too quickly, training in worn-out shoes, and running on hilly terrain and very soft surfaces. Physical problems can increase your risk for Achilles tendonitis. These include leg length differences, hip weakness, tight hamstrings and calves, weakness in the foot muscles, foot instability, and flat feet.
Achilles tendonitis also occurs in people with certain medical conditions: those with arthritis, diabetes, psoriasis, high blood pressure and thyroid disease. Certain medications are associated with Achilles tendonitis. These include antibiotics (Levaquin, ciprofloxacin, and other fluoroquinolones) and a group of medications taken to prevent breast cancer, aromatase inhibitors.
Initial treatment of Achilles tendonitis starts immediately and lasts 1 to 3 days, the goal being to reduce the pain and swelling around the Achilles tendon. Runners should stop running. Ice the painful tendon, try compression stockings, and elevate the foot for 15 to 20 minutes twice a day or more. Shoes with a slightly higher heel or a heel insert raise the heel and support the tendon.
Once you can walk with minimal pain consider physical therapy, and specifically an eccentric exercise program. It is a heel drop exercise based on the Hakan Alfredson’s protocol. Gentle calf stretching exercises help stretch the muscles and aid recovery. A plantar fasciitis night splint worn in bed is excellent for preventing calf muscles tightening up overnight. Cross training with swimming, aqua running, and biking if not painful, is important to maintain your training. Depending on how bad the injury is, it can take six weeks to several months to heal.
Other treatments that have been studied include Nitroglycerin patches over the tendon, 88% effective compared to placebo, with possible pain and healing potential. Laser treatments, soft tissue friction, and ultrasound do not have clear-cut study results, but may be offered by treatment facilities. NSAID medications such as Ibuprofen, Advil or Naprosyn may be helpful for pain, but after the first few days the effectiveness decreases. Platelet rich plasma (PRP) injections, although with good results in other tendons, have not had as good results for Achilles tendonitis in recent studies. Cortisone injections are not used in tendons, but may help with pain around the tendon.
Although you may not prevent Achilles tendonitis, you can certainly decrease your risk for it. When starting a new training program, increase duration and intensity gradually. Warm up at a slower pace, stop and rest if you note Achilles pain. Choose supportive shoes and replace them when they are worn out. Take time to stretch your Achilles in the morning when you get up, before and after exercise to maintain flexibility. This also helps to avoid a recurrence of tendonitis. Add calf and foot muscle strengthening to help the tendon better handle the physical stresses with your activities. Add balance and stability exercises done without shoes to improve stability of both your feet and ankles. Cross train, alternating high impact activities (running, jumping) with low impact activities (swimming, biking).
Nutrition is important for healing and maintaining quality tendons and ligaments. Foods rich in Zinc, Vitamin C, Omega 3 fatty acids, collagen and protein give tendons the building blocks to heal and keep tendons nourished. Consider drinking an organic bone broth, rich in collagen and the supporting minerals and vitamins. There are many good recipes available. Drink a mug full of bone broth in the morning and at night to help the healing process.
- DeLee JC, et al. Tendon injuries of the foot and ankle. In: DeLee & Drez's Orthopaedic Sports Medicine: Principles and Practice. 4th ed. Philadelphia, Pa.: Saunders Elsevier; 2015. http://www.clinicalkey.com. Accessed July 9, 2015.
- Ham P, et al. Achilles tendinopathy and tendon rupture. http://www.uptodate.com/home. Accessed July 9, 2015. Achilles tendinitis. American Orthopaedic Foot and Ankle Society. https://www.aofas.org/footcaremd/conditions/ailments-of-the-ankle/Pages/Achilles-Tendinitis.as
Bone Broth Recipe Calories: 379 per serving Prep Time: 10 minutes Cook Time: 25 minutes Total Time: 35 minutes Ingredients • 3-4 pounds beef marrow and knuckle bones • 2 pounds meaty bones such as short ribs • 1/2 cup raw apple cider vinegar • 4 quarts filtered water • 3 celery stalks, halved • 3 carrots, halved • 3 onions, quartered • Handful of fresh parsley • Sea salt
Serving Size: 3 Quarts Procedure • Place bones in a pot or a crockpot, add apple cider vinegar and water, and let the mixture sit for 1 hour so the vinegar can leach the mineral out of the bones. • Add more water if needed to cover the bones. • Add the vegetables bring to a boil and skim the scum from the top and discard. • Reduce to a low simmer, cover, and cook for 24-72 hours (if you're not comfortable leaving the pot to simmer overnight, turn off the heat and let it sit overnight, then turn it back on and let simmer all day the next day) • During the last 10 minutes of cooking, throw in a handful of fresh parsley for added flavor and minerals. • Let the broth cool and strain it, making sure all marrow is knocked out of the marrow bones and into the broth. • Add sea salt to taste and drink the broth as is or store in fridge up to 5 to 7 days or freezer up to 6 months for use in soups or stews.
What Athletes Should Know About Vitamin D
Find Vitamin D in these
by Dr. Inez Kelleher Lisa was surprised after her visit to the doctor. She had been tired for the past few months. Her 800 meter interval times confirmed that. They were about 5 to 10 seconds slower than they had been six months ago. And she hadn’t made any significant changes in her training. She was surprised because her blood tests found she was very deficient in Vitamin D. She wouldn’t have thought of that deficit as contributing to her fatigue. But it did. Three months later, after taking Vitamin D, her 800 meter times improved again. Lisa’s story isn’t unusual. (Often when athletes think of a nutrient deficiency related to performance they think of iron or the B vitamins…. And sometimes they’re right.) According to the Third National Health and Nutrition Study, more and more Americans have insufficient Vitamin D levels. About 77% of Americans have insufficient Vitamin D levels -- a significant increase over the last 30 years. Elite athletes are among them, according to recent studies. If you’re an athlete who lives in a northern climate or if your sport is mainly indoors, you are at a higher risk of Vitamin D insufficiency. The sun is the most plentiful source of Vitamin D. Cholesterol is converted to Vitamin D at skin level by the UV light from the sun. Exposure to the sun without a sunblock lotion for a minimum of 20 minutes daily is required for your skin to make enough Vitamin D to support its functions. But Vitamin D production may be comprised by various factors from the shade of your skin to your age. First, you can’t rely on making Vitamin D from the sun even if you live in a sunny climate. Scientists recently discovered Vitamin D deficiencies among those living in the Middle East, Australia, and Hawaii. Second, Vitamin D production may be compromised by your shade of skin. Dark skin absorbs less sunlight than light skin. Third, Vitamin D production has been found to be less efficient in those over 70. What Athletes Should Know As Sports Medicine and Nutrition studies show, restoring Vitamin D levels with supplementation correlates with improved muscle strength. Furthermore, research on athletes including soccer players, swimmers, and runners suggests improved performance, muscle strength and recovery, when vitamin D levels are restored and maintained at 40-50 ng/ml. Restoring Vitamin D to normal levels (30ng/ml-100ng/ml) has also been associated with fewer stress fractures, decreased bone and muscle pain, decreased infections and, among the elderly, a decreased number of falls. Insufficient (20-30 ng/ml) and deficient (<20 ng/ml) levels are associated with increased risk of stress fractures, and muscle injury, and infections. This is not surprising given the multiple functions of Vitamin D. It helps absorb calcium – which, in turn, affects bone development and growth, and even muscle strength and mass, especially as we get older. Studies have also found that Vitamin D helps lower inflammation and boost the immune system. How Much Vitamin Do You Need? That depends, given that Vitamin D is stored in fat and that our bodies vary in terms of how they produce Vitamin D. Some people have problems absorbing Vitamin D in their digestive tract. Other people take medications such proton pump inhibitors and some cholesterol-lowering drugs that can limit Vitamin D absorption in the gut, so a higher dose may be required to maintain Vitamin D functions. If you want to supplement Vitamin D intake for your needs, ask your physician to test your levels first, especially if you have suffered from stress fractures, bone and muscle pain, recent falls and frequent common infections, and injuries, or are taking medications that interfere with Vitamin D absorption. Vitamin D Sources Of course remember dietary sources with naturally occurring Vitamin D. These include fatty fish, salmon, egg yolks, and cheese. Fortified foods include cereals, milk, yogurt, soy milk, and orange juice. Vitamin D supplements are available as Vitamin D3 or Vitamin D2. Vitamin D3, ergocalciferol, is obtained from fish., Vitamin D2, cholecalciferol, is obtained from yeast and mushrooms. D3 is more easily absorbed but if you are vegan you may want D2. The main point is to take Vitamin D as needed. The recommended daily doses differ amongst medical specialties. The National Institute of Medicine recommends a daily dose of 600 International Units (IU) for adults aged 19 to 70, while the Endocrine Society recommends 1500-2000 IU for the same age group.
Fueling For Competition
Recently MOVE! hosted a talk on fueling and supplements with speakers by Dr. Inez Kelleher, orthopedic surgeon and silver medalist in the National Senior Games, and 2016 Olympic Triathlete Joe Maloy. Topics covered included foods/macronutrients for competition, Vitamins, and supplements including caffeine. The next note will focus on Joe’s thoughts on caffeine.
Regarding the question of whether or not to take supplements, Dr. Kelleher stressed that food is the best choice for nutrition – better than supplements. They, however, can help provide nutrient deficiencies not obtained in your diet. Magnesium is one trace mineral, for example, that is difficult to obtain enough of in your typical diet. (400 mg. is the current daily requirement. Magnesium is found in dark, leafy greens, seeds, nuts, whole grains, yogurt, and bananas.)
Dr. Kelleher discussed some supplements, such as Beta Alanine, that have been known to help with performance – with intensive anaerobic bursts lasting from one to four minutes. She stressed that if you do consider supplements, they should be used with moderation and careful thought. Critical to choice of supplements is to research the quality of the company that produces it. Some companies (such as Thorne) are known to control resources to be sure contaminants.
Dr. Kelleher reviewed the main functions of macronutrients and their recommended relative consumption. Carbohydrates supply energy, protein builds structure for building and repairing muscles, bones, organs, hormones, and enzymes, and fats provide energy and building blocks for natural steroid hormones including estrogen, testosterone and cortisol. Recommended ratios of consumption in a daily diet include 40 – 55% carbohydrates, 10-15% protein, and 30% fats.
How much protein should athletes ingest? As a general rule, 1-1.5gm per kg body weight or .45-.68 mg/lb divided in three to four servings per day is best. As an example, a woman weighing 125 pounds should consume from 56 to 85 grams of protein. Athletes should shoot for the higher end of that range.
Regarding timing of meals, as the link to the piece “Fuel for Training and Competition” (see below) indicates, a rule of thumb to have a meal one to three hours before your event. The article also suggests samples of pre-competition meals or snacks. Inez noted that it’s best to avoid eating high fat before training or competition to avoid feeling full and bloated.
During competition in events longer than a few hours, fuel with carbohydrates every 30 to 60 minutes. Fresh fruit, dry cereal, peanut butter and jelly sandwiches, crackers and fruit yogurt are good sources of carbohydrates.
“Fuel for Training and Competition” includes recommendations of timing of specific foods to eat if you are entered in a meet with several heats or events scheduled with breaks throughout the day. If you, for example, have a meet with one- to three-hour breaks, what do you eat? What do you eat afterwards?
After a workout or competition, nutrients should be replaced within 30 minutes, chocolate milk being an excellent replacement. Milk is 90% water. It offers a macronutrient ratio of 4:1 carbohydrates to protein. Carbohydrates refuel muscles after exercise. The calcium, vitamin D, and phosphorus build and muscle recovery. Milk’s potassium wards off muscle cramping. The B vitamins help convert food to energy.
Is It Plantar Fasciitis?
Plantar fasciitis, the most common cause of heel pain in adults in the United States, is associated with runners who overtrain, weight-bearing professions, poor footwear, decreased ankle motion, and obesity. Plantar fasciitis is caused by micro trauma and excessive strain to the plantar fascia, the stiff tissue that runs from the bottom of the heel to the base of the toes. This tissue supports the arch in the foot, particularly during toe off while walking and running.
You probably have plantar fasciitis if you have heel pain with your first steps in the morning or after sitting and resting. It can get worse throughout the day after prolonged standing.The pain will temporarily improve with rest, ice, and anti-inflammatory medicines. The good news is that 85 to 95% of those plagued with plantar fasciitis will respond well to non-surgical treatments.
If you have plantar fasciitis avoid barefoot activities and wear shoes with good support (cowboy boots work great). Plantar fascia specific stretches, foot muscle strengthening, night splints, heel cushions, and shoe inserts improve plantar fasciitis pain. Cross training to avoid excessive strain during healing is important.
For those with symptoms lasting longer than six months cortisone injections are considered. Surgery may be required for the 5 to 10% that do not get better. Some people will have x-rays which show a bone spur. This is not the cause of the pain. Anatomic studies have shown the spur is not located in the plantar fascia but it is associated with a small muscle in the foot. - dr. k
Relax in a Sauna and Improve Athletic Performance?
Saunas have long been used for several health benefits including high blood pressure control, immune system boost, body detoxification and post workout relaxation. Research findings support sauna therapy in post workout recovery, muscle growth and improved athletic endurance. In a recent study, running to exhaustion time improved 23-30% after sauna for three weeks, twice a week for 30 min. The researchers attributed this change to increased blood flow to the heart and increased plasma volume (natural blood doping?!). Since 1989 scientists have known Growth Hormone levels increase after sauna, supporting muscle growth and repair.
Lactic acid and uric acid from your muscles are found in sweat after workouts. Sweating in the sauna also helps your body remove toxic substances like heavy metals (mercury, lead, arsenic, cadmium) and organic pollutants such as BPA and pesticides. Some of these toxins are thought to be associated with chronic disease such as autoimmune disease, diabetes, Parkinson’s disease to name a few.
There are three main types of saunas, wet, dry, and infrared. The infrared sauna is considered the best, dry and steam also work the temperature is not as easy to control. Use caution when first starting saunas. Drink plenty of water, start slowly (3-4 min) and work up to 15-30 minutes. Always ask your doctor first if sauna therapy is all right for you.
Find a sauna near you; relax and sweat your way to improved performance! - dr. k
Don't Forget Fish Oil
Fats – the right kind of fats – are important in our diet. Like vitamins, Omega6 and Omega3 fatty acids (FA) are fats that are essential and our body cannot make them.
Omega6 oils are plentiful in our diet -- maybe too plentiful. Omega 3 is not. Omega 3 oils are important for all our cells' membranes, making them pliable, and fluid. Dry flakey skin may indicate a deficiency in your diet.
Omega 3 plays an important role in decreasing inflammation in our joints, muscles, and tendons. Studies also show a decrease in coronary artery disease and cardiovascular events in people taking fish oil supplements, as well as a decrease in Alzheimer's, and an increase in longevity.
Omega3 FA can be found in walnuts, flax seed,chia seeds, grass fed beef, certain eggs, tuna, trout, oysters, and sardines, to name a few foods. Typically, these are not consumed on a regular basis, so fish oil supplements can be used. They usually have two omega3 oils, DHA and EPA. They should total (DHA +EPA) 700 to 1000mg.
The USRDA has recommended a dietary intake of 1600mg for men and 1100mg for women. Some experts feel we need up to 4000mg per day. So consider taking 1100 to 4000mg depending on which guideline you want to follow. There is a prescription also available. For that, check with your doctor.
After a few weeks of Omega 3s, your joints may feel better especially if you have discomfort secondary to inflammation in your body (asthma, allergies, eczema). Also, if you have bumps on the back of your arms (keratosis pilaris) they may go away, your skin texture and dryness overall will improve.
- dr. k
Know About Magnesium
Why magnesium? It is a necessary element for many reactions in the body, including ALL ATP production. ATP supplies the energy for our muscles. Seventy percent of the magnesium is found in our bones and is important in influencing bone formation. The remaining 30% circulates in our body.
Over our lifetime a decrease in magnesium can affect the possibility of developing diseases such as hypertension, cardiovascular disease, diabetes, osteoporosis and migraines.
Daily requirements for women range from 310 to 320 mg. daily. The standard American diets tend to be deficient in magnesium. Medications that can prevent magnesium absorption are proton pump inhibitors (commonly used for reflux disease) and diuretics .
Some foods that are good sources of magnesium include spinach, quinoa, almonds, soy beans, halibut, and tuna. Ask your doctor for more advice.
And -- BTW -- magnesium is the prime ingredient in epsom salts. Soak in it and you will soothe your muscles.
- dr. k
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