T Nation

Prime Time- Dr. Ryan 8/3-4

Ready for questions.

Doc, what’s the most common type of back injury you see in athletes these days?

Dr.Ryan I’ve asked you a question a while back and I didn’t get a chance to tell you what happened.

So anyways I know that I have had a shoulder subluxation (very close to a full dislocation). Why is that if I try and do a pull-up or tricep pushdown,it fells like the teres major(other muscles around it) is being activated.It’s bigger and more noticeable on my right and gets in my way.

hey Doc
I just started getting a clicking in my left shoulder this week. It happens during close grip bp’s. Rotator cuff or possibly something else?


Most low back injuries in athletes are usually related to some combination of postural strain of normal activities of daily living combined with repetitive strain most commonly due to pattern overload related to their particular activity. These factors, coupled with either improper form/load/volume will lead to injury.

Regarding specific tissues that are injured, it is often difficult to tell since most people will try to either train around the problem or will live with it for some time before seeking treatment. By that time, the body has already started to compensate for the injured area and most likely has started to develop improper motor patterns, etc. Also, regardless of the tissue that was injured, it will effect the muscles, joints, discs, etc because the nature of how the body works.

Therefore, it is more important to assess the body’s response to movement, loading, etc, and try to develop a treatment program to focus on all the tissues as well as restoring functional movement patterns, etc.

Let me know if you have any follow-up questions.

Take care,


P.S Where are you located at these days?

I’m having some internet trouble tonight due to a storm we are getting. I will try to post as quickly as I can. Sorry.


Dear Dr. Ryan

What are you thoughts on chondroitin?

I have a friend who graduated from the Ontario Memorial Chiropractic College and he claims that while glucosamine is useful, chondroitin is basically useless ? I think it had to do something with absorbtion rates…do you have any comments- agree/disagree ?


Well, do you know what specific tissues you injured that allows your shoulder to sublux?

In general, the shoulder has a large ROM, which means that it sacrifices stability for mobility. As a result, the passive ligamentous capsule and the rotator cuff muscles are responsible for providing the shoulder it’s stability. An injury to the passive ligaments or just a general laxity of these tissues, will place a greater burden on the rotator cuff to provide the stablity. Pull-ups create a traction force on the shoulder. Since your shoulder has increased laxity, the muscles would have to work harder to prevent the shoulder from subluxating or dislocating. Obviously, the increased demand could create more muscle hypertropy. The press-downs create more of a compressive and translatory shear that would have to be accounted for by the muscles.

Without examining you and seeing the muscles, it is hard to give you more specific advice. What rotator cuff exercises have you been performing? Also, what do you mean by the muscle is ‘getting in your way’? What movements or exercises do you feel limited in because they ‘get in the way’?

Take care,



Clicking can be caused by a lot of things. Is there pain associated with the clicking? Does the clicking happen with every rep or just once? Any history of shoulder problems?

Regarding the close grip bench press, how close of a grip are you using? How long have you been doing the exercise? Have you recently changed any of your workout paramenters relating to this exercise? Is this the only exercise that causes clicking?

Take care,


It generally happens the first rep and then every few reps or so after and there is no real pain when it occurs. No history of shoulder issues either.

I’m spaced about 14" apart and have been doing them off and on for over a year now. Generally I was using them with lower reps\higher weight (10x3 or 7x4) then the past few weeks 3x12 at about 70% 1rm.

Marcus A,

Well of the two, glucosamine has received the majority of the attention. However, some studies have shown that both are effective. I’ll post a summary of one below. Off the top of my head, I don’t remember the absoprtion rate of chondroitin. I’ll have to check on that.

The summary:

NIAMS-Funded Analysis of Glucosamine/Chondroitin Sulfate Trials Shows Probable Usefulness for Osteoarthritis
Independent, High-Quality Clinical Trials Recommended

A systematic analysis of clinical trials on glucosamine and chondroitin sulfate for treating osteoarthritis (OA) has shown that these compounds may have some efficacy against the symptoms of this most common form of arthritis, in spite of problems with trial methodologies and possible biases. The study, by Timothy E. McAlindon, D.M., and colleagues at the Boston University School of Medicine, published in the March 15, 2000, issue of the Journal of the American Medical Association (JAMA),* recommends that additional, rigorous, independent studies be done of these compounds to determine their true efficacy and usefulness.

“About 21 million adults in the United States have OA,” says Stephen I. Katz, M.D., Ph.D., director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), which funded this study and has helped launch a major clinical trial on the compounds in OA, along with the National Center for Complementary and Alternative Medicine (NCCAM), both parts of the federal government’s National Institutes of Health (NIH). “Effective treatments are key to improving the quality of life of Americans affected by this common disorder.”

OA, also called degenerative joint disease, is caused by the breakdown of cartilage, which cushions the ends of bones within the joint. It is characterized by pain, joint damage, and limited motion. It generally occurs later in life, and most commonly affects the hands and large weight-bearing joints, such as the knees and hips.

The Boston researchers point out that glucosamine and chondroitin sulfate have received significant media attention and have been used in Europe for OA for over 10 years. The researchers say that physicians in the United States and the United Kingdom have been skeptical about these products, probably because of well-founded concerns about the quality of scientific trials conducted to test them. Glucosamine and chondroitin sulfate, which are sold in the United States as dietary supplements, are natural substances found in and around the cells of cartilage. Researchers believe these substances may help in the repair and maintenance of cartilage.

The Boston University team located 37 studies of the compounds in osteoarthritis by a thorough review of the scientific literature going back more than three decades. Of these, 15 trials published between 1980 and 1998 met their criteria: double-blind, randomized placebo-controlled trials that lasted four or more weeks, tested glucosamine or chondroitin for osteoarthritis of the knee or hip, and reported data that the team could extract on the effect of treatment on OA symptoms. Six of the 15 trials involved glucosamine and 9 used chondroitin. The team used only trials of four or more weeks duration because of evidence that it may take several weeks for the compounds to have a therapeutic benefit. Only one of the 15 trials was completely independent of manufacturer support.

The team’s analysis of the trials had two key facets: a quality assessment to evaluate each of the clinical trials and a meta-analysis, which enabled them to integrate the data from different trials. The trials studied had many methodological flaws and biases, including those that tended to inflate the benefits of the compounds. The team was also concerned that trials having small or negative effects might not have been published, but after contacting study authors and other experts, they could locate no unpublished negative results.

Based on data from the trials, the researchers calculated an overall “effect size” for the two compounds: the figure 0.2 is considered a small effect; 0.5, moderate; and 0.8, large. The researchers calculated an effect size for glucosamine of 0.44 and for chondroitin sulfate of 0.78, but reported that these values “were diminished when only high-quality or large trials were considered.”

“The results of this analysis performed by Boston University researchers underscore the critical public health need to test these agents in a rigorous way,” said Dr. Stephen E. Straus, director of the NCCAM. “The NCCAM and NIAMS have jointly initiated the largest multicenter study to date of glucosamine and chondroitin sulfate in order to provide Americans with definitive answers about their effectiveness for osteoarthritis,” Straus concluded. The University of Utah School of Medicine is coordinating a nine-center effort in over 1,000 patients, with recruitment to begin later this year.

In the meantime, says Dr. McAlindon, he would not discourage patients from trying these compounds, “but there is a possibility that they might not work,” and that substances labeled as these compounds might not even contain them, due to a lack of regulation. Both the Arthritis Foundation and the American College of Rheumatology have issued statements** urging patients with osteoarthritis not to stop proven treatments and disease-management techniques and to let their physicians know if they are considering use of these compounds.

The mission of the NIAMS is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on the progress of research in these diseases. More information on NIAMS is available at www.nih.gov/niams/. The NIH multicenter study is described at http://www.niams.nih.gov/ne/press/1999/09_15.htm.

*McAlindon TM, LaValley MP, Gulin JP, Felson DM. Glucosamine and Chondroitin Sulfate for Treatment of Osteoarthritis: A Systematic Quality Assessment and Meta-analysis. JAMA. 2000;283:1469-1475. Accompanying editorial: Towheed TE, Tassos PA. Glucosamine and Chondroitin for Treating Symptoms of Osteoarthritis: Evidence is Widely Touted but Incomplete. JAMA. 2000;283:1483-4.

If you made it this far, you may also want to check out this link for some additional info: www.spine-health.com/topics/conserv/nut/nut01.html

Take care,


yo Doc, how you doin? I ot a couple q’s concerning spinal decompression therapy, if you have the time. I have been doing some research concerning the “true” therapy- the axial decompretion therapy, not the traction table- and it seems to be pretty good. Problem is it requires a month of nearly daily treatments and i dont think ge will be to happy w/ me taking a month worth of half days… the closest provider is like 100miles away. anyhoo- i was wonderin what your general thoughts on it were, and if the treatment could be adapted by a skilled engineer that i could do myself. It appears that the treatment involves varying loads over time as opposed to simply applying a load and holding it.
ooh, and if you have the time- what do you think of the traction tables?

I seem to have developed some sort of injury in my right forearm. I thought it was a simple overuse injury when I first noticed it several weeks ago, as I had just got a pull up bar and started to do numerous reps throughout the day. The pain is located near my elbow, as in if I put my arm out in front of me with my thumb pointed up, at the bottom, inside of my forearm near the elbow joint, on the ulnar side. It was a sort of dull pain that especially bothered me when doing palms up pull ups.

Then, this morning I was doing explosive seated cable rows with a rope attachment, with my grip in sort of a neutral hammer fashion, and I got a much more acute pain in that part of my forearm, that seemed to extend distally down my forearm. Now, it was a shooting kind of pain, and it bothered me, but it wasn’t unbearable. As I’ve lived with this for weeks already, I did the dumb thing and continued my sets, just using a finger over thumbs hook grip on the rope. That seemed to help a little.

I just noticed that if I make a fist with my thumb pointing up, and flex my forearm, I can elicit that same shooting sensation, and it is definitely a sharp pain that starts on the ulnar side of my forearm, just below the elbow and goes towards my wrist.

Sorry for the rambling description, but I’m no good at explaining this.

What do you think it could be, and if it’s something I need to seek professional help for, what sort of professional do you suggest?

As always, thanks for taking your time out to chat with us.



Well the clicking could be a tendon popping over a boney area. In some people with a lax lig. the long head of the bicep can slide out of its groove which can create clicking. The glenoid labrum can be a cause of clicking.

As long as there is no pain, it is not as concerning. You may want to throw in some rotator cuff work to make sure no imbalance exists. Search Eric Cressey’s articles for a rotator cuff program. Also, try a slightly wider grip and see if it makes any difference.

Let me know how it goes.

Take care,


When doing chin-ups (supinated) I’ve been experiencing a shooting pain in the back of my neck after about 4 reps. I continue to crank out a couple more and end up with a throbbing pain in the back of my head. I sit down feeling kinda dizzy and it really takes a full minute to feel back to normal. I then complete my workout but feel like crap throughout.

This happened during my last 3 workouts so its not a one time thing. Obviously, I can stop doing chins - but I’m curious what’s going on. Maybe my form is too rigid, I’m straining too much to get my chin over the bar, or simply having a brain aneurysm (kidding, hopefully)? Any thoughts? Thanks.


Well the ‘decompression system’ you are talking about is a proprietary unit. However, there are many different types of axial traction tables that can perform the same basic procedure. Any doc with an axial traction table can place you in the same position and put a lumbar roll under your low back prior to starting the traction. Usually these machines have variable control settings that can either provide constant or intermittent traction. This therapy can be useful for disc injuries and nerve compression.

The seated back extension that they use to strengthen the muscles could, in certain circumstances, aggravate an injury as there is greater disc pressure with sitting.

I would check around your area for a doc that has an axial traction table (these are different than the inversion type traction tables) and can get you on a good lumbar spine rehab program.

I would also suggest that you get the book Ultimate Back Fitness and Performance by Stuart McGill. It will give you an excellent RH program as well as a great education on back injuries.

Regarding inversion tables, they can safely be used to decompress the spine in some people, but I wouldn’t recommend them for everyone. If you are healthy and don’t have any significant cardiovascular issues you can get some relief. However, if used improperly you could potentially aggravated your condition. If you get one, get one where you can stop the table at different degrees of inversion. Going from straight up to upside down would most likely create too much of a traction force.

Let me know if you have any follow up questions.

Take care,



By the looks of your avatar, I think you may be overworking your forearm.

Actually it sound like you may be getting some tendinitis or medial epicondylitis.

I would suggest that you find a good sports med chiro or PT in your area that can do a good assessment and then provide some therapy. Some ultrasound, myofascial release and RH exercise should help. They should be able to help fix it and if not, they can refer you for imaging or to an ortho.

For the time being, I would use wrist wraps for any exercise that requires you to grip intensely. That will help to relieve some of the strain on the muscles and give them a chance to heal. Also, ice massage the area after workouts to help limit inflammation.

Keep me posted on how you are doing.

Take care,


Dear Dr. Ryan

As a chiropractor, you probably have the best insight into this. I’ve asked this to CT before, but I’d appreciate your opinion on this. There are some clowns in my gym who keep pissing me off by telling me high bar squats compress the cervical spine and are actually very damaging, yada yada…

I think it’s BS – and so do alot of others (CT, etc) but given that you’re on the other end and you actually see patients and diagnose them – what are you thoughts ? Dogma or fact ?

today at practice i got fucked up playin steal the bacon. i ran right into some one, ther head hit me right in the jaw on the lower right side, about an inch from my chin. now on the left side of my face where my jaw connects to my head hurts unbelieviably. its hard to speak and i cannot chew. the trainer says its ok, but what the hell hurts so bad and why


Definitely get checked out.

Do you get these symptoms with any other exercises? What about with head positions?

Do you have any medical conditions?

When performing your chins is your head extended? What kind of breathing pattern do you use when chinning?

Take care,