Stop Picking the Scab

When treating painful conditions, an essential, and often ignored factor is removing the irritants causing the problem. The unhealthy world we live in provides an endless supply of irritants and causes of imbalances and pain that we are not always aware of. Some of these include sitting, workstations, cars, mattresses, computers and smart devices, shoes, sports, exercise, hobbies, foods, certain people – the list goes on and on.

Many of us, especially as children, have been told, “Don’t pick the scab,” after cutting or scraping our skin. The reason being that as the skin heals, we do not want to disrupt the process by picking at the scab. If we were to consistently pick at it, the wound would continue to open and would not heal. This is what happens in painful conditions where either the causative factor is not determined, or it is determined but patient does not make the necessary changes to remove it.

“Picking the scab” is a term used by Stuart McGill, Ph.D, one of the top lumbar spine researchers in the world. One of McGill’s main points in treating lower back pain is determining the causative factors and making changes in the patient’s lifestyle that will protect the spine and prevent further irritation. This is what is meant by not picking the scab.

This sounds like a very simple approach when compared to extensive treatments, drugs, surgeries, etc, but is often much easier said than done. When looking at all the possible causative factors for our pain, it may seem impossible to avoid them all. The first step is awareness – identifying the factors. Once identified, one can then make decisions on altering lifestyle. If the causes cannot be removed completely, it is important to try to create as much balance as possible in order to counteract the negative aspects as much as possible.

A common mistake in dealing with pain is making generalizations such as, “I just have to stretch more”, “I just have to exercise more”, “I have to do Pilates”, “I have to get adjusted more”, etc. While sometimes there is some truth to these generalizations, we must realize that every individual is unique and has different needs. What is true for one is not necessarily true for another. And it is often not about getting more, it is about getting what is right for the individual – quality instead of quantity.

Here are some examples of questions to ask your healthcare providers:

What types of exercise would be most appropriate?
What type of stretching would be most appropriate and when?
What movements or positions should I avoid?
How can I alter my workstation?
How can my diet affect my condition?
What else can I be doing on my own to help myself?
What types of treatments would be best for my situation so that I improve function and get the most out of life?

Keep in mind that the healthcare provider is not the healer. The patient is the true healer. It is their body that is changing, doing what it was naturally designed to do. The provider has an important role in helping to guide the patient on his or her journey, advising and providing services/products that allow the patient to heal more efficiently. Patients must take responsibility for their health, and healthcare providers must empower them to do so. By understanding the underlying causes of our conditions, we can take action to create a healthier lifestyle allowing our bodies to heal and thrive.

Plantar Plate

OPA!!! Did you “break” your plantar plate?

Plantar PlateMany patient’s present to my office complaining of “ball of foot pain”.  Many things can be occurring in the wonderfully complex forefoot, and many times, we are able to differentiate pa theologies based on the description of symptoms.  One particular issue which I am seeing more and more of is something that many people have never heard of; the plantar plate rupture.

The plantar plate is a cup like ligament that provides support to the plantar aspect of the metatarsophalangeal joint (or the bottom of the joint connecting the toe to the long metatarsal bone associated with it). This provides stability to the joint, and helps prevent dorsal dislocation when walking and running.

The plantar plate can sometimes suffer injury. This can be the result of a direct trauma, but I more often see it as a result of repetitive stress or “wear and tear”. These injuries are often associated with an elongated metatarsal. Over time, the ligament frays and weakens, eventually leading to attenuation or rupture. This will lead often lead to a toe deviating to the side. Most commonly, I see this occurring to the 2nd or 3rd metatarsophalangeal joint.  An MRI or detailed musculoskeletal ultrasound is often extremely helpful in evaluating the damage to the plantar plate, and in differentiating plantar plate pathology from other forefoot pain such as neuromas.


What is Functional Training?

Today there are so many different opinions on how one should exercise. “What type of training should I be doing?” is the big question. “Do I perform slow or fast reps? Do I use a bench or a physio-ball? Do I do one body part at a time?” The answer is that everyone should be training in a manner that relates to their individual goals. There is no set routine that equally benefits everyone who does it. Performing a typical gym program of random exercises, three sets of ten, with one minute rests has benefits but will not be the most efficient way to attain your goals or address your specific needs. Training primarily with machines and not using free weights is inefficient because you are moving resistance along a fixed axis, and not freely in space as the body normally functions. Machines have limited functional strength transfer to real life situations in most cases, and can actually create poor motor patterns in some people. Machines have value when integrated properly but are often misused.

Functional training is defined as movements or exercises that improve a person’s ability to complete their daily activities or to achieve a specific goal. It is not a series of exercises deemed functional by some manual. Doing movements in the gym that strengthen the muscles involved in the movements you wish to improve outside the gym is a good start. This does not mean you can simply add weight to the exact movement you wish to enhance. There is research that has proven doing this can actually be detrimental to some athletic movements. When a baseball player adds weight to his bat that can actually slow his bat speed down because the added resistance changes the forces on the joint and disrupts mechanics. All exercises have some functional value when applied correctly, this value is determined by the exercises transferable benefit outside the gym. Every exercise has a functional limitation and it is up to the trainer to understand what it is. A good program focuses on weak areas and sets specific goals for the client. It is important to understand how to progress someone from simple smaller targeted movements to more complex multi joint movements. Training someone functionally can range from having a tennis player lunge to a chop or a body builder do a slow curl for bigger biceps; its all about the goal.  Keep in mind doing complex movements before the client is ready will do more harm than good.

In order to build appropriate muscle strength, joint integrity, balance and flexibility in all planes of motion, it is essential that the body is exercised in a functional manner. It is crucial to include multi-joint and multi-planar exercises, as this recruits the body’s stabilizers to synergistically facilitate movement. Doing this ensures that the nervous system is working properly and that all  parts of the body are used in the appropriate manner, with the correct muscles firing at the right time. This is not to say you shouldn’t include some so called non functional exercises, including a machine or old school exercise can be beneficial, safe and fun when applied correctly. To create a functional program, a trainer must set realistic goals and understand the client’s weaknesses, daily activities and limitations.

A trainer must be able to identify postural distortions and include exercises that correct them, but more importantly they have to educate the client on what movements or activities to avoid or modify during their day. It’s not what you do; it’s how you do it. The ability to identify a postural distortion is dependent on the trainer’s understanding of anatomy, motor patterns and muscle function. A trainer must also be able to identify when muscles are over active and firing out of sequence, or not firing at all. Synergistic dominance is common in most postural dysfunctions. In general, if the agonist is tight then the antagonist is weak, thus creating increased stress on the joint. This can result in patterns of repetitive stress, ultimately leading to accelerated joint degeneration .

Core stability, flexibility and balance are key factors when designing a functional exercise routine. It is important to maintain posture while being able to move all joints in a full range of motion. Training with free weights, and challenging the surrounding environment promotes balance and stability, which is necessary if you expect to see benefits outside of the gym. Keep in mind, it is more important to be able to control your own body weight and concentrate on form, balance and core endurance, than to move heavy weights.

A functional core routine consists of dynamic movements, isometric exercises and challenges the center of gravity. To completely train the core, you must also include dynamic stabilization, isometric and proprioceptive movements, not just for the mid section, but for the entire trunk. Medicine balls, balance boards, foam rollers and physio-balls are great tools for core training, and should be integrated into every program. It is a fact that training on the physio-ball (challenged environment) is superior to traditional floor exercises. As a person ages, balance and stability become compromised. If balance and stability are not addressed, they will consistently degrade. A weak core contributes to poor stability, and inhibits proper limb movements, causing muscle imbalances in the kinetic chain. This is why falls are common in the geriatric population. Many back and hip injuries are related to weak core muscles. There are many small muscles in the core that the general population knows little about or addresses during exercise. In most spinal injuries,  MRI images show atrophy in these small muscles. In order to maintain a healthy spine, these little muscles need to be trained. Without stability, even the strongest person can not effectively propel a force into the environment.

Flexibility is a very important facet of any exercise program, but is often over looked.  Lack of flexibility in the right places appears to be the root of many problems. The body’s movements are hampered when flexibility and posture are distorted. Active, dynamic, static and PNF stretching are key factors and should all be included in any training program. When a muscle is tight, it limits the muscle’s ability to contract properly, causing inefficient movements and risk of injury. Without flexibility, the body’s movement becomes limited, and good results are difficult to achieve.

This article has explained the key components of a functional program and its benefits. Traditional weight lifting is a thing of the past, and has been proven to produce limited results compared to a functional program. The only way to enhance movement is to mimic the movement in the gym until it becomes autonomous in every day life. Before initiating any exercise program, one should always consult a physician, as well as a qualified fitness professional. This insures that they are addressing their specific needs and goals



Q) Should I do slow repetitions or fast?

A) You base the speed of the repetition on the speed of the required activity. The body needs to be trained at the same or a higher velocity during exercise to benefit a particular activity. A sprinter doesn’t jog to increase their speed. In my opinion slow training is good for form training, rehabilitation and hypertrophy.

Q) My friend works out at the local gym and mostly uses machines. He has been doing the same routine forever and has gotten good results. Is this program good for me?

A) NO! Any exercise program will produce results whether it is done right or wrong if you stick to it. Unfortunately when exercise is done incorrectly the harmful affects may not be noticed until the damage is done. By exercising functionally you will systematically attain your goals and insure that your time in the gym is spent safely and efficiently. Just because someone looks good does not mean they are an expert.

Q) Can functional training benefit anyone?

A) Yes. Functional workouts are beneficial for any athletic level or age group. By training functionally your time in the gym is spent more efficiently. When you train in this fashion you will see drastic improvement in overall health and performance not just appearance.

Q) Shouldn’t I do cardio and lose weight before I start a functional program?

A) NO! You should have a functional training program that concentrates on raising and lowering your heart rate. The program should first use body weight exercises then advance to free weights. This promotes lean muscle mass, skeletal integrity and healthy cardiac function. Muscle mass accelerates fat loss.

Q) My friend tells me to do 3-5 sets 10-12 reps to failure with 1 minute rest intervals.

A) This is what everyone who thinks of the gym envisions. Unless you are a body builder this is not a good program. If you train in a functional fashion you burn more calories and get more benefit from your sessions outside of the gym.

Q) Aren’t aerobic classes and the treadmill enough?

A) NO! A weight training program that includes balance, core stability strength and cardiac conditioning builds lean muscle mass. When you build muscle you burn more calories at rest and during daily activities. Which would mean, by adding resistance to your program you actually will burn more calories doing the same aerobic class or distance on the treadmill?

Q) Should I stretch before or after exercise or an event?

A) Evidence demonstrates that static stretching before an activity is not beneficial to prevent injury. If you want to avoid injury you need to be flexible by stretching regularly and not just before activity. Active and dynamic stretches with a short warm up mimicking activity before, P.N.F and static stretching at the end help remove waste from the muscles.

Q) Why have none of my doctors told me to stretch and exercise to alleviate pain?

A) Unfortunately we live in a society of doctors that prescribe meds for everything imaginable. Everyone wants immediate gratification (pill) not a long term solution (exercise). The fact is most people would ignore the doctors’ request to stretch and exercise then seek a new doctor for a simpler solution. Most minor health problems can be eliminated by moderate exercising but people choose to take meds because they are lazy.

Q) I injured my knee and my doctor told me to rest it for a while. Do I?

A) This is the worst thing you can do. Pampering an injury for extended periods causes muscle atrophy and decreased blood flow. All injuries should be functionally rehabilitated under careful supervision.

Q) Should I cut carbs out of my diet?

A) NO! Cut high glycemic carbs out only. Carbohydrates are essential for cellular function. Eating carbs that do not spike insulin levels is healthy and effective for weight loss.

Q) My doctor told me to walk to get some exercise for my aches. Is walking enough?

A) NO WAY. If walking were enough basically everyone would be healthy we all walk. If you have pain chances are there is a biomechanical issue. My first suggestion would be to stretch. More walking will only aggravate the issue. You need to correct the imbalance first not just walk more.


Charles DeFrancesco

E-mail :



1: Cosio-Lima LM, Reynolds KL, Winter C, Paolone V, Jones MT.

Effects of physioball and conventional floor exercises on early phase adaptations in back and abdominal core stability and balance in women.
J Strength Cond. Res.2003 Nov;17(4):721-5

2: Hides, J. A., Richardson, C. A., and Jull, G. A. Magnetic resonance imaging and

ultrasonography of the lumbar multifidus muscle. Comparison of two different

modalities. Spine 20:54-8; 1995

3: Hides, J. A., Stokes, M. J., Saide, M., Jull, G. A., and Cooper, D. H. Evidence of

lumbar multifidus muscle wasting ipsilateral to symptoms in patients with

acute/subacute low back pain. Spine 19:165-72; 1994

4: Kiyoshi Yoshihara, MD; Yasumasa Shirai, MD; Yoshihito Nakayama, MD; Shinji Uesaka, MD. Histochemical Changes in the Multifidus Muscle in Patients With Lumbar Intervertebral Disc Herniation. Spine 2001;26:622-626

5: Julie A. Hides, PhD; Carolyn A. Richardson, PhD; Gwendolen A. Jull, MPhty Multifidus Muscle Recovery Is Not Automatic After Resolution of Acute, First-Episode Low Back Pain. Spine 1996;21:2763-2769

6: Etty Griffin LY.

Neuromuscular training and injury prevention in sports.
Clin Orthop.2003 Apr;(409):53-60

processed foods (1)

The Danger of Processed Foods

Processed foods are a staple in the American diet, and as a result, we are a heavier, sicker population overall. Processed foods are generally recognized as any food that comes in cans, bags, boxes, or jars, especially if they have a long list of ingredients on the label!  Processed foods are very easy and convenient; however, they contain many ingredients used to soften, preserve, color, emulsify, bleach, flavor, and hide odors.  These chemicals have been shown to cause cancer, obesity, and heart disease. Consequently, processed foods should be avoided as much as possible.

One reason processed foods have negative health effects is because they are usually very high in sugar or high fructose corn syrup. This sugar laden food is filled with empty calories and negatively affects metabolism.  Additionally, excessive sugar intake has been linked with high triglycerides, high cholesterol, and insulin resistance. Fructose is especially damaging and toxic to the liver, since that is where it is primarily metabolized. It also turns directly into fat and leads to obesity and issues with the mitochondria (the powerhouse of the cell), which also has a role in metabolism.

In addition to sugar, processed foods contain a large variety of artificial ingredients. These ingredients are not real food! They are chemicals used as preservatives, colorants, flavors, or texturants. Further, some of the chemicals in the food may not even be listed on the label and might be grouped in an all-encompassing term, such as “artificial flavors.” Supposedly, these chemicals have been tested for their safety, but how can all of these foreign chemicals actually be good for us?  A great deal of research shows that certain preservatives are linked to allergic reactions, cancer, and other health issues. For example, the preservative BHA affects the nervous system and has been shown to change behavior. Food colorings and flavorings also have negative health outcomes. In fact, nine food dyes are linked to hyperactivity and cancer, while a flavoring called diacetyl may be linked to Alzheimer’s disease.

Processed foods are also high in refined carbohydrates, which pass through the digestive system quickly and raise blood glucose levels and insulin levels. This has been associated with many chronic diseases and negative health effects. Additionally, these foods are generally low in fiber, because the fiber is lost during processing. Fiber is responsible for slowing the absorption of food, increasing satiety, normalizing bowel movements, and lowering cholesterol.  When foods pass through the digestive system quickly, we require less calories to digest them. Therefore, in a shorter period of time, we can eat more and burn less, a recipe for weight gain!  Overall, there is very little nutritional value in processed foods, even when vitamins and mineral are “added back” into the foods.

Many people complain that they can’t stop snacking on processed foods, and they have intense cravings for these items. Research shows that many of these foods have been engineered to be rewarding and desirable to the brain, which makes the food addicting and makes it difficult to stop eating.  Even though our bodies are designed to regulate how much we eat, food manufacturers have designed their foods to be “hyper-rewarding” and to bypass these intrinsic regulators. Additionally, since processed foods are missing important components like water, fiber, and nutrients, the hormones in your body do not know how to respond or digest these foods properly.

Today’s society is busy, stressed and overwhelmed, so processed foods may seem like an easy solution. However, in order to remain productive and healthy, it is important to eat real food. Real food with real nutrients will make us look better and feel better!

Sports Injury

The Mental Side of Sports Injury Rehabilitation

The physical demands required to practice a sport quite often lead to injuries. Last year, 1,5 million young athletes incurred in some kind of a serious injury. Strains and sprains, about 500,000, are the most common sport injuries, followed by fractures and contusions. Once an athlete suffers a sport injury, physical rehabilitation plays a positive and significant role in helping the athlete return to the field, track, or course. As the athlete commits to the rehabilitation process, he/she will notice physical improvements and, in due time, be back to practicing his/her favorite sport. However, injury rehabilitation is not just about addressing the physical pain. Injured athletes often experience a wide array of emotions that, unless properly managed, may impact not only in the rehabilitation process, but also the chances of successfully returning to completion.

Once an injury occurs, emotions invade the athlete’s mind. Regardless of the kind of injury, the athlete is suddenly forced to stop from participating in his/her favorite sport. The longer the rehabilitation process is, the stronger the emotions that are experienced. A sport injury can become an emotionally devastated moment for any athlete. Dreams of remaining in the varsity team, or hopes to receive a full scholarship ride to a top division school may have just become a gone possibility. At the time when education is running at exorbitant costs, parents may also experience a sudden emotional shock. The rehabilitation process is not just a physical demand, but equally important, a mental exercise that will demand focus, emotional determination, and positive reinforcement not only for the athlete, but also for the parents.

Addressing the emotional aspect in sport rehabilitation has many positive benefits. Setbacks, like an injury, is likely to challenge the mental makeup of the athlete. Chances are that the athlete will be able to come back and fully participate in his/her sport again. However, the athlete’s chosen mental approach to overcome this difficult moment can become a learned lesson for dealing with future sport and life challenges. It is in the athlete’s best interest to take full responsibility to embrace the mental side of sport rehabilitation as it will lead to developing a higher level of confidence knowing that he/she was able to successfully navigate the challenges and disappointments of a sport injury and return to play.

Injuries bring a wide array of emotions. An athlete will feel frustration, anger, sadness, depression, nervousness, and even hopelessness. All these emotions may be experienced one after another or some of them all at once. The athlete’s routine has just been broken and the sports goals need now to be temporarily put on a shelf. There is no worse experience for any athlete than sitting on a chair and thinking “why me?” The athlete will try to find answers and, in the process, become emotionally overtaken by the hopelessness of not being able to participate in his/her favorite sport. The longer the rehabilitation process, the more likely the athlete will go into an emotional tsunami of experiences.

Some of the emotions are related to the uncertainty of whether the athlete will be able to compete again, and how soon that will happen. Also, the athlete may fear being replaced by another athlete and losing his/her place in the team. Additionally, there is also the fear of not being able to achieve the top physical fitness prior to the injury or, even worse, the fear of being re-injured. Parents may directly or indirectly make this challenging experience even more difficult by undermining or short-cutting the rehabilitation process in hope of raising the athlete’s emotional state. Unfortunately, this approach often leads to not only increasing the chances for recurring injuries, but more importantly, to missing the opportunity to build a stronger emotional state that will help the athlete cope with future challenges.

There are important and useful mental approaches that positively impact injury rehabilitation for both, athletes and parents.


  • It is perfectly fine to have emotions concerning the injury. It is an unexpected set-back. However, the same mental fortitude that led he/she to succeed in sports can be applied toward the rehabilitation process. A positive mental attitude directed toward rehabilitation will promote quicker healing.
  • Set specific and realistic goals directed toward rehabilitation. Make sure you follow proper physical, dietitian and rest guidance. The athletes must commit to meeting those goals even when progress is not moving as fast as he/she wishes.
  • Surround yourself with encouraging people that will support the recovery process. There may be times when the athlete will feel down and discouraged. By maintaining contact with teammates, coach and/or even taking the role of mentoring other players will bring positive and fulfilling feelings.
  • Practice positive imagery. Athletes have successfully used this mental strategy to bring faster healing. The body has gone through a lot of stress, both physically and emotionally. To alleviate stress, mental imagery helps to lessen stress and facilitates rapid recovery.
  • Another strategy to lessen stress is to practice breathing relaxation. Athletes are encouraged to lie down on a coach and place a light object on the belly. With each inhale, push the object up and then exhale. Repeat this exercise for five minutes and bring attention to how the body begins to calm down.


  • Empathy goes a long way in the recovery process. The athletes need a secured presence for support, encourage, and understanding. It is also important for the parents to remain in contact with other sport parents and coaches for guidance and support, as well.
  • Take a pro-active approach to understand as much as you can about the injury, its potential outcome after surgery, the needed rehabilitation program while also maintaining contact with the athletic trainer, physical trainer and coaches. It is important to remain connected with these professionals in order to be truthful and supportive during the entire process.
  • It is normal that the athlete goes through emotional ups and downs. It will hard on them as it will on the parents. At this moment, it is important to remain positive and encourage the athlete to follow with professional recommendations and goals. It is detrimental for the athletes to minimize recovery time as it will only increase the chances of getting hurt, again.
  • If the athlete struggles with the recovery process and it is taking a big emotional toll, keep the professionals informed and consider seeking mental health sport counseling. As hard a recovery process is, the athlete may benefit by addressing his/her emotional struggles with a separate professional that will provide mental health support.

As unfortunate a sport injury is, there is a silver lining behind successfully addressing the recovery of a sport injury. The athlete will have gained the be more confident after having adhered to a set of goals, remain positive, be patient, seek help, and build mental toughness that will be useful to deal with future sport and life challenges.


Alex Diaz, PhD

Sports Mental Edge

Tennis Elbow

Tennis Elbow

Rick Weinstein, MD, MBA
Director of Orthopedic Surgery Westchester Health Associates

One of the most common problems I see in the office is tennis elbow. Most people with this problem don’t even play tennis! Tennis elbow is damage to a tendon where it attaches to the elbow. The muscles that extend your wrist start as a tendon on the outside part of the elbow, and when this is injured, it results in tennis elbow pain. Repetitive motion of the wrist or excessive lifting with the arm and wrist is what causes the problem. I commonly see this in both athletes and non-athletes as well.

The pain is localized to the outside part of the elbow. It is worse with lifting with that arm and typically does not hurt when resting. Pain can be severe and is often felt when shaking someone else’s hand. If the pain is on the inside of the elbow, it is called golfer’s elbow and is due to an injury to the wrist flexors, not the extensors.

The best way to treat tennis elbow, like any other injury, is to prevent it. If you are going to play a sport you should be in shape before the season starts. This means cardio conditioning and strengthening legs and arms. Stretching is also key to preventing injury.

If you have tennis elbow, treatment for 95% of people is without surgery. I start my patients in physical therapy, but this should be with a good therapist who deals with this problem a lot. If you are having severe pain or have had symptoms for a long time, a cortisone shot can provide dramatic improvement. I do these under ultrasound guidance to ensure accurate placement. The few patients who don’t get better with therapy and injections will require surgery. The surgery takes me only about 20 minutes, and my patients go home the same day. The surgery is very successful, but again should only be performed if you really have done adequate therapy and injections. I also do PRP injections if the cortisone does not work.

Tennis elbow is very common, and if you suspect you have it, see an orthopedic sports specialist to get it checked. If your doctor tells you need surgery, and you have not done much therapy and injections, get a second opinion. Pain in the elbow or any other part of your body after working out or playing sports should be treated initially with ice and rest. If pain persists, call an orthopedic specialist.