Training Driven By Diagnosis: Exercise Your Stabilizers

Pec Major stabilizes abduction
Public Domain

Stabilizers are a group of muscles that offer the possibility to obtain large increases in power and accuracy as well as prevent injuries.  Many people overlook this important group of muscles in their athletic training.  Let’s look at:

  • What are stabilizer muscles
  • Why are they important to train
  • Why they don’t develop adequately from practice
  • How to improve them
What Are Stabilizer Muscles?

These are muscles that contribute to an agonist or prime mover muscle’s function via reducing movement of some related bone. The ‘stabilizer muscle’ term is most often used in the context of action on the same joint(s) as the agonist but the term can also be applied on distal, functionally related joints. In either case, stabilizers do not directly contribute to the agonist’s movement of a bone, but they do contribute to the total power output and control of a movement.  Every joint involved in golfing uses multiple stabilizer muscles. Let’s see some examples.

Deltoid - BP3d
By Anatomography

Example: Same Joint Stabilization

When you do your arm back, your right arm is using the middle / posterior fibers of the deltoid muscle (the blue fibers in the graphic) to lift your arm up and back.  If the humerus were not constrained within the shallow socket  (note the shallow socket on the left scapula in the skeleton graphic) of the scapula by other muscles, it would dislocate superiorly every

Public Domain
Public Domain

time you did a backswing.  Fibers of the lower portion of the pectoralis major and to a lesser degree, the teres minor muscle work to pull the head of the humerus down, keeping it in the shallow socket, at the same time as the deltoid is pulling the arm backward. In this example, the pectoralis major is a stabilizer muscle.

Humerus Stabilization with Pec Major
By Dr. Wallman

Example: Distant Stabilization

“For every action, there is an equal and opposite reaction.”

Newtons Third Law

By Jeffrey Beall CC 3.0
By Jeffrey Beall CC 3.0

How does this manifest in sports?  For a football quarterback throwing a ball, they straighten their arm rapidly to push the ball forward off of their hand.  The shoulder end of their humerus is also pushing in the opposite direction as the arm straightens.  It is only by having a relatively stable scapula attached to a fixed torso which allows all the force to go forward into the ball.

If the muscles holding the scapula to their torso are weaker than the forces being exerted on it by the arm straightening muscles, some of the force will cause their scapula to stretch backward.  This results in some percentage of the force being generated by straightening their arm going into scapula movement rather than propelling the ball forward.  In other words, weak scapula stabilizer muscles result in the ball traveling slower over a shorter distance.

By Ducky2315 CC 3.0
By Ducky2315 CC 3.0

This loss of effective power being delivered to the target in golf (the club and ball) because of weakness in a stabilizer muscle of a related joint can happen anywhere along the kinetic chain of a movement.  For golfers, power starts at the points where cleats push against the ground. Some force can be lost by not having cleats and being on slippery ground.  In this case, the rear foot would slip backward during the swing.  In a similar manner, weak ankle stabilizers will results in the foot bowing outward instead of that force being transferred up the chain.  The same for knees that bow, hips that wobble, each and every vertebra that stretches the wrong way, robbing power rather than contributing power to the drive.  Stabilizer muscles at every joint along the kinetic chain stop unnecessary movement so that there is a potential to maximize force being transferred to the club head.

Why Are They Important To Train?

These are some of the outcomes achieved by gaining better control and power from your stabilizer muscles:

  • Local Power – They keep the fulcrum of each individual joint ‘centered’ properly during movement to optimize biomechanics and power of that joint.
  • Combined Power – Having adequate strength and control of each stabilizer in your body allows you to add more cumulative power to your shots rather than robbing power from your stronger muscles.
  • Consistent Shots – Clicking joints are a prominent sign that your joints are not being stabilized properly and could be moving unpredictably during a stroke.   Loose joints are less noticeable than clicks, but have the same impact of decreased accuracy.  This makes it very difficult to hit the same shot time after time.  Even half a mm of extra play in a dozen joints throughout the body accumulates so that body movements are difficult to control with precision and consistency.
  • Health – Weak stabilizers allow local joints or other parts of the body to move excessively, stretching tissues abnormally, causing damage and eventually pain.
  • Career Longevity – Accumulated stretching of soft tissues by poorly stabilized joints leads to accelerated damage and joint degeneration that results in prematurely ending athletic careers and yoga practices.
Why don’t they develop adequately during practice

Increasing effective control and strength in a muscle is a combination of many factors including: increased muscle mass; elimination of intramuscular fibrosis & trigger points; recruitment of more muscle fibers during contraction, enhancing neurological control and coordinated timing.  Prime movers will experience some improvement of these parameters through playing golf, particularly enhancing nerve control and coordination.  Stabilizers rarely get conscious attention during play and typically do not get enough usage to result in significant improvement.

Let’s look at a couple of the factors in muscle strength development so you can see why training stabilizer muscles in isolation and reintegrating them back into your swing can be so much more effective.

Increasing Muscle Mass

Increasing muscle mass requires introducing micro-tears into the muscle so that it stimulates the body to repair the damage and make it just a little bit stronger to prevent future damage.  This is done by exceeding the muscle’s capacity through repetitive use of the muscle or increasing the amount of weight that the muscle is pulling against.

Muscle developmentFor example, in golfing, the swing muscles are typically used only once every 3-10 minutes.  This pattern does not lead to the repetitions that are conducive to obtaining micro tears that stimulate growth.  Increasing resistance on the stabilizer muscles through contractions of stabilizers near their maximum output during a swing are also very unlikely to happen.  The majority of force in a swing is exerted by the agonist muscles and stabilizers typically only use a percentage of their maximum potential force which doesn’t stimulate growth.

Neurological Control

Control of stabilizer muscles are frequently far from a golfers thoughts during their shot routines.  It is often difficult to determine if a stabilizer is working or not, unless you isolate the movement and the muscle involved.

Internal and external rotation of tibia - yiss-anatomy2010-11.wikispaces.comOne knee stabilizer that I frequently check involves control of rotation of the tibia at the knee.  Try this on yourself.  Sit with your hips and knees bent at 90 degrees.  Lift one foot off the ground a few inches and dorsi flex your foot (pull your toes and foot upwards using your ankle muscles).  Keep your foot in this position and without moving your thigh at all, rotate your lower leg around the axis of the tibia (i.e. if you placed your heel on a nail sticking out of the floor and twist your lower leg so the heel stays in place and your forefoot rotates from pointing to the outside and pointing to the inside).

80% of the people I test for this stabilizer muscle have no control over the motion at all. The bend their ankle but do not rotate their tibia.  They do not have neurological control over the muscles that perform this motion. It usually takes 2-4 weeks to gain minimal control overs this motion and another 2-3 months to gain power and speed of movement.

Without control of this movement, your knees will not be stabilized properly, will not contribute to the total power of your sport and leave you vulnerable to injury.

How to improve stabilizer muscles
Dr. John Wallman
Dr. John Wallman

First…..diagnose which stabilizers are too weak, which too strong and which are normal.  This requires testing individual muscles.  You can do this by focusing on one specific joint and testing all the muscles there and comparing them to other muscles around that joint and against the paired muscle on the opposite side. Alternatively, you can do more disseminated testing, possibly testing all the muscles in the body.  Testing may be done by a number of different muscle strength testing techniques including: manual; isokinetic; tensitometry; computerized movement imaging, etc.

Second….make sure that the cause of the weakness of the stabilizers is amenable to treatment by exercise.  You don’t necessarily want to be exercising a muscle where the weakness is caused by a nerve, bone or other pathological problem.

Exercise band - peroneus brevisThird…..exercise the muscles that are weak from lack of sufficient exercise or minor traumas with exercises that target only the individual weak muscle.  You don’t want to be exercise multiple muscles simultaneously, particularly if you end up increasing the strength of muscles that are already normal or too strong.    Which specific exercise you do can be further refined by what aspect of the muscle you want to address. I.E. increase muscle mass, break up trigger points, recruitment, etc.

Fourth….A muscle that has recently achieved significant improvements of strength may cause some shifting of stress points, neurological control and even technique requirements. Because of this step, you may need to reintegrate the muscle back into your stroke.  This step is not always required.

Reintegration is begun by initially deconstructing the golf swing into small components (i.e. on the downswing, a deconstructed swing might be broken into: a) push down or back on the right foot; b) rotate the knee; c) rotate the hip; d) rotate lumbars; rotate the thoracic region; drive the lead arm down; etc.).  Then start reconstructing the stroke by combining the newly strengthened muscle with one of its neighbors in a subset of the swing that just includes those two joints.  Exercise just those two components of the swing using proper timing, motion and then speed. Once remastered, combine the ‘new’ muscle with two neighbors.  Continue in this manner, adding one new neighbor at a time, until the entire swing is reconstructed.

Excerpt from upcoming book by Dr. John Wallman “Golf: Training Driven By Diagnosis”

Train for the results you want!


Kayaker - MSWhat does that mean?  If you want to improve strength, do a strength building program.  If you want cardio benefits, do a cardio building program, If you want to improve joint balance, do a joint balancing program. This applies no matter what goals you have: flexibility; endurance; skill specific; joint integrity; etc.

How do I know if I have the right program for my goals?

Measure!  Test the parameter you want to improve.  Recheck it on a regular basis.  Depending on what factor you want to improve, you might be retesting every week.  Most programs that are obtaining success should result in measurable improvements every 4-6 weeks.

Some parameters may be difficult to test.  For example, how do you measure your endurance capacity?  There are so many variables.  Have you been building the right type of muscle fibers? Are you building new capillaries? Red blood cells?  How is your carbohydrate storage capacity?  Are you looking to improve endurance for specific muscles or systemically?

PulseFor those parameters that are more difficult to test directly, you can sometimes monitor progress by looking at the training loads you are able to accommodate.  In other words, does your exercise program incorporate the idea of progressive increases of the factor you wish to improve?  For example, if your goal is to strengthen muscles, your exercise program must take into account increasing weights.  If you are looking to improve your endurance, your program must include progressive increases in the length of the exercise sessions.

For example, if you want to improve your muscle strength, and your exercise program has you lifting the same amount of weight, for the same number of repetitions, for the same number of days per week, you don’t have a good strength building program.  Here is an essential component of an effective strength building program for the biceps.
Start: Arm curls – 10 lbs., 10 reps., 3 days per week
Each week: Add 5 more pounds, same number of reps, same number of days per week  i.e. Week 2 @ 15 lb.      Week 3 @ 20 lbs.      Week 4@ 25 lbs.

Man studying street mapIf you want to successfully reach your goal, I find the following concept helpful.

  • Where are you?
  • Where do you want to be?
  • How do you get there?

With people I have worked with in the past, there usually not any difficulty finding exercise programs (how do you get there). A fair number of people have not considered their exercise options and clearly defined what goals they want to achieve (where do you want to be). What  seems to cause the greatest difficulty is knowing where you are, or what are your current capabilities.  Regarding individual muscle strength and joint imbalance issues, you can learn how to monitor individual muscle strength and imbalances through courses offered by the DxF.

What is your vitamin D status this flu season?


Blowing nose - MSWe’re coming into the flu season and with it, the annual promotions of the flu vaccine. Is that a valid strategy?  Let’s first look at health care workers and flu vaccines.  The percentage of health care workers who get the flu vaccine has historically been quite low. Only 20% of physician in 2003 were getting the annual flu vaccine (1).   One reason health professional flu vaccination rates are so low has been attributed to the fact that doctors and other health care workers are better informed of the risk benefit ratios with the flu vaccine.

Here is some other interesting data regarding the flu vaccines.  Each year, the vaccine manufacturers must estimate which strains of flu will spread during the upcoming season.  They must begin manufacturing the vaccine before they know for certain which strains will be involved.  This results in some years where the flu vaccines totally miss the strains that are causing infections.  This happened in “1968 and 1997, the strain of vaccines produced didn’t match the circulating viruses that season, which meant that, in effect, nobody was vaccinated those years. And yet death rates from all diseases including flu related illness did not change at all. ” (3)

Researcher - MSThe Cochran Collaborative is one of the most widely respected heath research organizations in the world.  They have come out on three separate occasions saying, “there’s no evidence flu shots work effectively”(1)  Also, ” the study found no credible evidence the vaccines afforded any protection against complications such as pneumonia or death but did increase the potential side effects. ” (1)  This gets even worse.  “Those results, as bad as they were, might actually overstate the case for vaccine effectiveness, the researchers cautioned, because many of the studies – 15 of 36 trials with funding declarations – were industry initiatives.”  and ” less publicized studies funded from public sources were significantly less likely to report conclusions favorable to the vaccines.” (1)

If vaccines are not effective against the flu, what measures can be taken to help?  The only way to know how to treat a disease reliably is by knowing why you are getting the disease in the first place.  With some people it is because they are low in vitamin D (4), with others, vitamin C, with a third person, it is because they have blood sugar levels that are too high.  Still another person will get the flu because their vitamin A levels are too low.

Magnifying glass child - MSIf the cause of your particular case of the flu is because you are low in vitamin D and you increase your vitamin C levels (another potential treatment for flu), you probably won’t experience any change in your flu symptoms or duration.  You could then take lots of zinc, another remedy linked to helping with the flu, yet you get no results.  Until you brought your vitamin D levels up to normal, you are likely to experience poor or no results with your flu infection compared to doing nothing.

Looking for the cause of the disease is the key.  Note I am not just talking about diagnosing what you have (i.e. flu).  I am talking about diagnosing why you have a disease.  This is causal diagnosis.  Otherwise, when you take a therapy, without knowing what is causing the disease, you are just taking a shot in the dark.

1 –
2 –
3 –
4 – Am J Clin Nutr (March 10, 2010). doi:10.3945/ajcn.2009.29094

Anterior Compartment Syndrome


Ballet dancers legs - MSAnterior compartment syndrome (ACS) is a complication of damage in the front lateral portion of the lower leg that can cause moderate to severe muscle and nerve damage.  Let’s look at the anatomy of the compartment, describe what the syndrome is, how to identify it and what can cause it.


The anterior compartment is a section of the lower leg between the knee and ankles.  It is bounded by the tibia and fibula bones on either side,, the tough interosseous membrane between these two bones forms the back wall and a tough outer membrane just below the skin forms the front wall.  The anterior compartment contains these four muscles:

  • Tibialis anterior
  • Extensor digitorum longus
  • Extensor hallucis longus
  • Fibularis tertius

What is Anterior Compartment Syndrome

The bones as well as the tough membranes forming and back and front walls do not stretch easily when there is any type of swelling within the compartment.  As a result, any fluid accumulation that results from let’s say, a pulled muscle,, does not result in swelling as easily as it does in other areas of the body.  Instead, there is an increase in pressure as fluid increases from the inflammation.

The result of that increased pressure is that the thinner walled veins and lymph vessels that are contained within the compartment tend to gradually collapse as the pressure increases from an inflammation.  The thicker walled arteries however, continue to deliver blood.  This results in further increase in fluid in the anterior compartment as blood gets in faster than it can get out. This vicious cycle can continue until the pressure is so severe that it can eventually collapse the arteries as well.

At this point, all of the tissues become starved for oxygen and tissue damage spreads to include all of the muscles, nerves and other tissues in the compartment.  This tissue damage resulting from oxygen starvation can be quite severe and can progress to the point of a medical emergency.


Magnifying glass child - MSACS needs to be differentiated from its much more mild ‘shin splint’ counterpart.  Shin splints are a fairly vaguely defined term referring to pain in the shin region, typically resulting from pulled muscles.  Pulled muscles in the anterior compartment can cause pain and even some degree of pressurization and circulation imbalance.  The key feature which differentiates anterior compartment pulled muscles from the ‘syndrome’ is a circulation imbalance that gets to the point of collapsing the arteries.

At this stage, you have anterior compartment syndrome and there will be no pulses in the region.   The collapsed arteries will also cause the region to be pale, quite the opposite from most painful areas which tend to be more red than normal color.  Pain will not be influenced as you would normally expect with analgesics due to the degree and type of tissue damage.  Parastesias or tingling will begin in the anterior compartment region or possibly into the foot once the nerves become damaged from lack of oxygen.  Paralysis will ultimately occur in the muscles within the compartment and further down into the foot as a result of oxygen starved nerve damage and to some degree even muscle cell death.


While ACS is most directly the result of a greater than normal amount of damage in an area which cannot tolerate extensive swelling, other factors can contribute to its frequency or severity.  These include items that fall roughly into the following categories: 1) increased rate of damage; 2) decreased rate of repair; 3) impaired inflammation regulation.

Tib Ant - Sup view - half body1) Increased rate of damage – If damage is happening to the muscles in the anterior compartment faster than it can be repaired in a person with normal, healthy repair processes, the amount of damage and associated inflammation will accumulate until the syndrome threshold is reached.  Factors that can increase the rate of damage include excessive strain from unusual activities (trapeze artists hanging from feet, marching through deep mud, lots of lateral kicks, trauma & severe lateral ankle sprain).  Abnormal strain can also be placed on muscles in the compartment with people doing relatively normal activities when they have imbalanced muscles in the region.  The imbalances increase the amount of strain and tissue damage relative to the actual stress placed on the muscle.

Carpentry - MS2) Decreased Rate of Repair – People who experience relatively normal amounts of strain but decreased rates of repair compared to optimum, will also accumulate more active tissue damage and associated swelling than they should.  Many factors influence rates of repair including: suboptimal essential nutrient status of any of the nutrients used in muscle repair (essential amino acids, vitamin C, magnesium, zinc, etc.); drug side effects that inhibit or compete with tissue repair or essential nutrients; abnormal sugar regulation (diabetes, hypoglycemia); other metabolic and disease states).

3) Impaired Inflammation Regulation – Inflammation is a normal part of any repair process.  In some people however, there is inflammation disproportionate to the amount of damage they receive.  This can happen when: they do not produce enough cortisone (adrenal fatigue, low cholesterol, statin drug side effect); they take in too many inflammation producing chemicals (omega 6 fats, air pollution, non-organic foods, drug reaction, etc.); allergy systemic response (food allergies, ‘hay fever’, etc.),

As with so many health conditions, it is frequently not a matter of just one cause.  It is important to explore as many possible contributing factors as you can with your healthcare provider to see which ones are involved and to what degree each is involved.  It is not unusual to find that 4-8 different factors involved, each contributing to your specific syndrome profile.  Some factors contribute just a little to your ACS, while others contribute a lot.  That is why the treatments that worked for your friend or neighbor, might have little to no effect for you.  The key is to diagnose the causes first, then treat.

Images courtesy of

1, 2, 4 – Microsoft, used with permission

3 – john Wallman

Have you tried…….


Puzzled lookWe hear this every day.  “I’ve got a back ache.” Someone else replies, “Have you tried leg lifts?” or “Do sit ups.”  or “Try this yoga pose” or any number of other options.  And many people will try them… all…one after the other.  Until the problem is fixed, goes away or gets worse.  Through the decades, I have received far too many patients as the result of well meaning, but totally inappropriate health care recommendations.

This scenario is repeated over and over again for almost every imaginable condition.  “I’ve got x”  and “Try Y, it worked for me.”  Unfortunately (or fortunately), everybody is different, and the causes for one person’s health condition can be very different for the next.

This pattern is skipping the critically important step.  Asking the question “Why?”  Why do I have condition X?  Until that question is answered, every therapy is a matter of trial and error.  You might even try the correct therapy, but stop too soon because you didn’t understand what was causing the problem, how extensive it was and how long you needed to keep doing it.

This situation of starting therapies before the cause is known is not limited to the public.  Health care providers frequently skip asking the question ‘why’ before starting therapy.  This does not mean in emergency situations you shouldn’t do whatever you can to try to keep somebody alive until you have the time to figure out in more detail what went wrong.  It’s always important to balance the time available for your diagnosis strategy and when treatment needs to begin.

On the other hand, all too often, diagnosing for the cause is never looked for or is inappropriately dismissed with the phrase “the cause is not known”.   There are many times I have heard this phrase used for conditions I, my father and grand uncle have checked the scientific literature for and found reliable therapies that we have used to treat and cure so called idiopathic conditions.  A more appropriate phrase would be “I do not know what the cause is” or “I have not done a diagnostic workup to determine the cause of your health condition”.

The time period between when vitamin C was discovered to cure scurvy and it was in common usage was 200 years.  How many people during those 200 years died because they were told, “The cause for scurvy is not known”?  How many times was it because that therapist did not know of the connection, did not research for what was already known about the issue, ‘intentional blindness’ or worst yet, knew that there was a possible connection between condition X and treatment Y, but did not look in this specific patient.

There are thousands of diet methods, vitamins, drugs, exercises, emotional techniques, etc. etc. etc.  The question we at the Diagnosis Foundation have is, “Of all the possible treatments for condition X that are available, how do I know if your particular recommendation is the one that I need to do?  What is the test(s) that will answer the question that method Y is just the right one for me to do now.”

There are an incredible amount of valuable experience, knowledge and intelligence in the world.  Most of you have great therapies that you have recommended at one time or another for some condition. Some of you know how to differentiate when your therapy is the perfect one to do, and when you should consider some other approach.

This is the information we want to know and help to inform others about.

How do you test that treatment X is the best thing to do for condition Y, above all the other potential therapies that are available?

Tell us your experience.  We want to know!

How many causes of high blood pressure are there?



Sphygmomanometer - MSA) 1
B) 2-6
C) 7-20
D) 21-100
E) 101+

There are at least 120 different causes of high blood pressure.  These are just the well accepted, well documented and researched causes, we’re not getting into any controversial issues here.

The thing I find most interesting about this factoid, is that almost all of them are curable, relatively quickly and with little cost once you discover the cause.  The difficult part is diagnosing which cause(s) are involved.  With the diagnosis process, it’s not that the tests to rule in or out each of these mechanisms are that hard to do or expensive (although a few of them might require brain surgery).  Almost all of these mechanisms can be diagnosed with relatively simple, inexpensive tests.

The difficult part is doing the detective work. Figuring out which mechanisms are involved, how many are involved, what proportion each of these mechanisms contribute to the high blood pressure, some causes have seasonal influences, etc.  Even with these diagnostic complications, it is not a horrendous task to figure out what is causing high blood pressure many times.

It frequently just takes looking, thinking, trying a few possibilities here, checking a few more possibilities next time.  Treat each mechanism that shows up outside of the normal range and see if there is a response with blood pressure.  I’ve found with this approach, it’s not unusual to find blood pressure going down within a few weeks, and being consistently normal within a year.

My favorite saying for this situation is: “If you want to see, you’ve got to look.”

What can cause muscle strength imbalances?


Vintage Balance ScaleThere are many possible causes of muscle strength imbalances.  One of the more common causes is that the strength you have in each individual muscle, is a result of all the activities that you do over time.  Activities such as walking, standing, sitting, exercising, going to the gym, or any sport activity, all lead to improvement of strength in the muscle fibers that are used in that activity.  Depending on the combination of all the activities you do, some muscles may eventually get stronger than others.

Imbalanced muscle strength can happen whether you are an Olympic athlete or relatively inactive.  For athletes, you might be exercising some muscles every week, but missing other specific muscles in your routines. Even if you are relatively inactive, factors such as your posture and the exact way that you sit, stand or walk all contribute to which specific muscles are used and developed.  The result of uneven exercising or activity levels is imbalanced muscles that can cause joints problems.

Other possible causes of imbalanced muscle strength includes: traumas, surgery, nerve problems, circulatory issues, nutritional deficiencies, drug reactions and more.  While these causes tend to be less common, it is important to rule out these mechanisms before beginning any treatment or exercise program designed to correct muscle imbalances.

Where are you? Where do you want to be? How do you get there?


Man studying street mapWhat do I mean by this?  It is my goal for a new health care system that can be summarized by:

  • 1st – Diagnose the cause
  • 2nd – Define your health goals
  • 3rd – Begin treatment

Where are you? – Diagnosing the state of the patient.  When I use the term ‘diagnosis’, I intend a couple of concepts that may not be included in many people’s definitions.

1) Deep – I intend diagnosis to have depth, to include understanding root causes.  Diagnosing ‘diabetes’ or ‘high blood pressure’ is a nice start, but it is a very superficial diagnosis.  I am referring to a deep diagnosis that includes understanding why a patient has those conditions.  Is the diabetes due to insulin insufficiency, insulin release timing or insulin resistance? Is the issue related to essential nutrient deficiencies (zinc, chromium, magnesium, etc.)?  The research data regarding causes of disease is far more advanced than many people realize.  Deep diagnosis includes looking beyond the superficial diagnosis and understanding causes.

2) Broad – I also intend diagnosis to be broad as well as deep.  To cover all the human dimensions: body, mind, spirit, social and environmental.  Many patients and doctors are now actively looking for root causes of health conditions, but what if the root cause is not in the physical?  How many patients with physical ailments have psychological, social, environmental or even spiritual factors as root causes?  How many people with psychological issues have physical causes?  I have seen this over and over again.

As an example, think of the patient you might know who is obsessed with their sickness.  They talk frequently not about getting well or having great vitality, but instead, obsessing on how horrible they feel.  They are looking to get their needs answered by being ill. In this example.  This type of patient is frequently resistant to implementing what might be relatively simple lifestyle changes that could cure their condition. Until diagnosis encompases a wider range of possible causes, we are limiting our chances of successful outcomes. It is time to broaden our diagnostic vision.

Where do you want to be? – Personal goals.  Why is it important to spend time discussing personal health goals as part of the new health care system?  The assumption is that everybody wants to be pain free and functioning at maximum effectiveness, but is that always the case?   What if maintaining the current: diet, lifestyle, family relationships, living environment, etc. has a higher priority in the patient’s mind?

A common example here is regarding weight loss.  Many patients come in saying they wish to lose weight, but on closer questioning, they have factors supporting the idea of maintaining their excess weight.  They may be uncomfortable with the attention they receive when slim, they might not want to change their lifestyle, they might be trying to punish a spouse or like how they feel with the added weight, etc. etc.  What will the patient be doing consciously or unconsciously to sabotage their success when their stated goal is at odds with other unarticulated desires?

When there are multiple goals, it is necessary to identify them, prioritize them and resolve any conflicts.  This will enable efficient efforts by all people involved in the health care recovery program and improve outcomes.

How do you get there? – Treatment.  In this area of the new health care paradigme, I also intend a couple of things that may not be included in the common definitions.

1) Sequence – Diagnose the cause first, then start treatment. (in non-emergency situations).  This may seem obvious.  Why would you want to jump from the frying pan into the fire?  But think of this…how many times have you known patients, friends and therapists start recommending treatments without first finding out what the patient really needs or what they want to achieve?  Think of how many times you have seen somebody start taking ritalin for ADHD without first looking at serotonin or tryptophan levels, allergies, toxic buildups or omega 3 fatty acid status?  How many times have you heard somebody say something like “Try this food, It worked wonders for me”.

2) Personalized care – We live in a time where standards and protocols define the rules for how people should be diagnosed and treated.  This model of health care contains a certain degree of assumption that everybody has the same causes for each condition.  We know this is not a valid model in some areas of health so why should we apply this same approach so broadly?

For example, with fevers,, we know these can be because of infection, injury, sunburn, exertion, toxic reaction or medication side effect just to name a few.  Nobody would think of applying antibiotics to someone who had just run a race.  Why do we treat everybody who has high blood pressure essentially the same?  In a review of the literature, there are at least 100 different causes of high blood pressure.  Treating everybody with the same methods will likely obtain poor results for obtaining a cure 99% of the time.

Summary   Overall, there is too much emphasis placed on what to do, and not enough on what is needed or what is desired. I would like to suggest that more attention be given to a deep and broad understanding of  what the patient’s current status is and clarifying goals before recommending any treatment.

When traveling, we wouldn’t do any of the following and expect a successful journey:

  • We’re beginning our trip from someplace in North America (Are you N, S E or W of your destination?)
  • We want to arrive over there… someplace…. (How about 123 Main Street, Anytown, NY for a specific address to travel towards?)
  • Everybody go north by north east! (No matter where you are starting from or where you are trying to go)

‘If you don’t really care where you end up, then it doesn’t really matter which way you go.’  Adapted from Alice in Wonderland

It’s time to plan our health care journey with the same  level of detail and systematic approach we use when planning our other types of traveling.

Diet or Supplements?


Food vs. PillsMany people have discussions about whether or not they should take supplements, when the more important questions is what does your body need.  Before starting any therapy program: nutrition; exercise; drugs; surgery; even meditation, it is important to know why your body is the way it is and what is needed to change your capabilities to meet your goals.

Regarding supplements vs. diet, there are approximately 42 essential nutrients.  These are the chemicals currently known that you need to ingest on a regular basis in order to survive, grow, repair and reproduce.  If you get the proper levels of these 42 chemical into your body, you’re capable of converting them into all the other chemicals you need.  If you have abnormalities in your body’s levels of any of these 42 essential nutrients, you will develop some type of serious health problem.

Lab testing and physical examination by someone trained in clinical nutrition are a couple of ways to answer the question of whether or not each of your 42 essential nutrients are high, low or normal.  In some cases, symptoms or a specific physical sign can be used as a reliable indicator of an essential nutrient status.  Much more commonly, symptoms and signs can have multiple causes.  In these cases, objective, direct measurement of the individual essential nutrients through lab tests are the more reliable way to proceed.

The next step after determining what essential nutrients your body needs, is to determine why any of the essential nutrients are abnormal. Are you not ingesting enough? Not digesting or absorbing the essential nutrients properly? Are you utilizing your essential nutrients too fast? Are you excreting them too fast?  Let’s look at examples regarding a couple of these.

You are not ingesting enough of an essential nutrient.  Let’s say you just don’t like certain foods, and they just happen to be all the good sources of one of the essential nutrients.  If that is the only cause of an essential nutrient deficiency that you have, supplements may make sense.  As another example, what if your deficiency is the result of a digestion or absorption problem?  In that cause, it might not matter what form you take the nutrient in (diet or pill).  You just won’t get replenished until you correct the digestion issue or find some other way to work around the malabsorption problem.

Once you have answered the questions of 1) what essential nutrient levels are abnormal and 2) why are they abnormal, the final step of 3) how to return your essential nutrients to normal levels is usually much easier to understand.  At that point, the question of whether or not to get them through supplements or foods becomes a relatively minor factor.

The ultimate goal is always to try and move from drugs to supplements to foods.  Foods are the best source of nutrients in terms of quality. They have properties that make them superior to manufactured drugs and supplements such as co-factors, enzyme activity, and other undiscovered nutrients.  The decision whether to use foods or supplements requires a finer level of detail than a blanket binary choice. Matching your source of nutrients with your current health status is an important factor in this decision.

If diet is adequate in returning your essential nutrient status back to normal in the time frame desired, then diet may be the preferred way to proceed. If the progress of returning your essential nutrient status back to normal through diet alone is too slow, then modifications in the treatment approach are needed. Supplements are one of the alternatives to consider when essential nutrient status normalization needs to happen faster.

The key concept in the previous paragraph is “returning your essential nutrient status back to normal”.  This implies rechecking your levels with repeat lab tests during the treatment phase.  Symptoms and signs can be helpful to monitor progress with replenishing some deficiencies in some situations, but not always.  In order to prevent yourself from trying to replenish an essential nutrient for too short or too long of a time period (and the potential for overdosing), get regular retests to monitor progress.

The overall point I would like to make with this article is, before having a discussion about what form should be used to replenish any nutritional deficiencies (diet vs. supplements), it is critically important to strive to understand what nutritional deficiencies are present and why they are there.  Diagnose first, then treat.

You go to the gym, exercise or do yoga, and now your joint clicks….what next?



Soccer Player Holding Injured Knee --- Image by © Royalty-Free/Corbis

Diagnose the cause! While some clicks and noises in the joints are relatively ok, others mean that something is wrong.  How can you tell? Should you just wait and see what happens?

No!  Waiting could be just the wrong choice. Some noises are the early warning signs that the joint is not working right.  These kinds of issues can frequently be fixed rather quickly if caught early enough.  Let it continue for too long, and you may find that at some some day, ‘out of the blue’ major damage occurs.  A spinal disc ruptures, a cartilage gets cut, bony spurs are discovered on x-rays. Now you can’t do the activities like you once could and recovery is likely to be a lot longer and the residuals will be much higher.

Let’s go into a little more details on the mechanisms for clicking and noisy joints as well as some of the potential underlying causes.

Clicking joints can come from:

  • The bones of the joint are not centered properly – and moving out of their socket/groove
  • The bone is riding out of the proper position, rolling over cartilage of some other tissue improperly
  • A tendon near the joint is dislocating out of its’ groove or proper position
  • Ligaments are loose allowing the bones to move excessively
  • The joint is malpositioned such that movement causes excessive suction and a sudden fluid shift causing a ‘pop’ like when you pull a finger knuckle.  Even a well positioned joint can be made to ‘pop’ if enough force is put on it.  (The mechanism is similar to pulling a wet suction cup off of a flat surface)
  • Cartilage or other soft tissue has been damaged and a piece has broken off, with the bone rolling over it.
  • Calcium deposits have built up around the joint that rub against some other tissue with movement

What are some causes? – Most of these possibilities are caused directly or indirectly by, or a long term complication of, some kind of imbalance in a joint.  Imbalances can come about for many reasons including:

  • Trauma – stretching or damaging muscles, tendons or ligaments, etc.
  • Surgery – intentionally damaging, muscles etc.
  • Muscle imbalances – from activities that exercise certain muscles more than others
  • Connective tissue imbalances – from over stretching joints in some direction
  • Nerve issues – causing muscle contractions to be too strong or too weak in certain directions
  • Circulation issues – causing a buildup or deficiency of chemicals that are needed to allow the muscles to work properly
  • Bone issues – malformed bones from trauma, birth defect or other cause
  • Other – scar tissue, pressure from swollen tissues,

Does that mean it’s time to stop exercising? That you are too old?  No.  but it does mean that something needs to change.  Pushing through joint clicking is very likely to exacerbate the problem.

Find the cause! – The first thing to do is find out why the joint is clicking.  If you have addressed the issue sooner rather than later, the odds are improved that you can fix the cause relatively quickly.  If instead, you have ignored the clicking, covered it over with pain medication or tried to work through it, the odds are increased that it will take a longer period of time to fix.

Where can you start to address a clicking joint?   If you have noticed the clicking fairly quickly after it has started, a thorough history of what you were doing near the time when it began can many time reveal the cause.  You may be able to do this yourself to some degree.  Answer these questions:

  • Where does it click?
  • When does it click?  With what motions?  Is it repetitive or just once every hour or so?
  • Is it painful?  Does it have any other sensations with it? (dull, tingling, burning, itchy, etc.)
  • Do any symptoms linger after the clicking?
  • When did it first start?  What were you doing right then? For the days before?  The week before?
  • Has it been getting better or worse?
  • Have you had this before?  If so, what treatments did you use?  Did it help?
  • Any change in workout routine?  If you lift a lot, spend some good time looking carefully at the possibility that you have altered your routine, or been working out some muscles more than others.
  • Change in DIet?  Supplements? Medications?

If you are not able to figure out and fix the clicking relatively rapidly through your own investigations, get somebody with more experience to look at all of the possibilities.  Find somebody to work with who understands possible causes of a clicking joint and knows how to determine which ones are involved. The greater the number of possible causes of clicking your health partner can determine, the more likely that you will be able to do all your health work with one health or fitness provider.

Some of the skills you want your provider to be trained and experienced with include:

  • Able to evaluate individual muscle strength & balance
  • Able to measure joint ranges of motion & connective tissue integrity
  • Able to determine nerve & vascular competence
  • Able to determine functional motions, timing and control of joint movement
  • Access to ordering x-ray, MRI or other imaging tests.
  • Most importantly – you want your health & fitness partners to be able to talk with you and work with you.  In most situations, you will get far better results when you know what is going on and are an active participant in the recovery process.

The main thing, is don’t ignore it and don’t cover it up and hope it will go away.  Typically, the quicker you start work on a clicking joint, the easier it will be to fix, and the less residual scar tissue or other damage you will have.