What Is Shoulder Impingement Syndrome?

As a physical therapist this is a complicated question and the fix can also be complex.  The shoulder by far is one of the most complicated joints in the body.  It has the greatest amount of movement than any other joint in our bodies.  And do you really have shoulder impingement syndrome?  As a practitioner, if someone comes to me with a prescription or request to treat shoulder impingement syndrome, I'm not going to just look at the shoulder.  I'm going to do an evaluation and assessment on the neck or cervical spine as well.  As I stated, shoulders are complex joints requiring a very skilled practitioner to correctly diagnose impingement syndrome.  Obviously something is impinged.  It's either the shoulder or something coming from the cervical spine.  But for this article, I'm going to just stick with the shoulder joint.  I'm making a firm diagnoses for this article that a person does have  "shoulder" impingement syndrome.

So What Is Shoulder Impingement Syndrome?

From my point of view, this is simply answered.  It is when the tissue underneath the roof of the shoulder gets pinched when the arm is moved in a specific manner.  So now, what's the next question?  

How Do You Resolve Impingement Syndrome?

This is the hard part.  Sometimes it's easy but most of the time it takes some work by the physical therapist and especially by the patient.  Before we go into answering how you get rid of it, we have to look at the anatomy of the shoulder to understand its' mechanics so that the right treatment application can be applied.

The Rotator Cuff Muscles & Shoulder Anatomy

On the left side of the diagram, you'll see the four muscles of the rotator cuff (RTC).  On the right side of the picture you can see that the RTC muscles are what steer the humeral head in that very tiny socket on the shoulder blade or scapula that's called the glenoid fossa.  So, when looking at the size of the humeral head and then looking at the size of the socket that the humeral head sits in, it's quite remarkable what the RTC has to do.  The RTC is responsible for making sure the humeral head sits in that tiny socket.  The attachments of the four RTC muscles are all within the red circle.  The space between the acromium process and the top of the humeral head are where shoulder impingement occurs.  The muscles of the RTC elevate the hummers to a certain point and rotate the humerus inward and outward. 

So why do some people acquire shoulder impingement syndrome and some don't?

Again, we have to look at some more anatomy of the shoulder.  Below are three different types of shoulders.  

Type I Acromium Process

Type I acromium process (AC) is where the bony structure at the edge of the scapula or shoulder blade turns slightly upwards.  Unless there is severe weakness or trauma to this type of shoulder, impingement syndrome does not occur often in a type I acromium process.  These are the people that usually do not have to worry about shoulder impingement syndrome.

Type II Acromium Process

With a type II AC process, the bony structure on the end of the scapula protrudes out laterally or just slightly downwards.  A type II AC process is the most common type.  With a type II process, acquiring impingement syndrome is more likely than a type I.  With a type II AC process, there is usually an aggravating factor that brings about impingement syndrome vs. the type of AC process listed next.

Type III Acromium Process

With a type III AC process, the end of the bony protrusion of the scapula orients itself in a hooked or downward position.  This type of process as you may have already surmised is very common with acquiring impingement syndrome.  Typically if a person has a type III AC process, then some point in their life they will have to tend to resolving shoulder impingement syndrome.

As previously stated, impingement syndrome is when the soft tissue becomes compressed between the head of the humerus and the AC process.  The next question is:

What Role Do The RTC Muscles Have With Regards To Impingement Syndrome?

The RTC muscles are what steer the head of the humerus in that tiny little socket.  So, if one of the RTC muscles becomes weakened then this means that this particular RTC muscle is not doing its job and the humerus is not staying centered in the socket.  When the humerus doesn't stay centered it then begins to "bang" against structures adjacent to the humerus.  This means structures above it as well.  These include the RTC tendons and the lubricating sack called the bursa.  When this occurs, it causes an inflammatory response.  When an inflammatory response occurs this means swelling.  Given the way the shoulder is already built, there isn't much room for any type of inflammation to occupy this space.  There's also no room for extra movement of the humerus outside of the socket or glenoid fossa.  When the humerus moves too much with impingement syndrome, it can also aggravate the bursa that lies on top of the humeral head and just under the AC process.  This bursa is a lubricating  sack that allows the tissues such as the RTC muscles to glide smoothly and evenly under the AC process.  But if the humeral head is not being steered properly by the RTC muscles, this bursa too can become aggravated and inflamed.  When the bursa becomes inflamed, it too swells and takes up space between the humerus and AC process.  So, let's take a look at what's happening now.

1. RTC muscles become weak and do not properly steer the head of the humerus in it's socket.
2. Because of this extra movement of the humerus, it bangs against tissues that it's not supposed to bang against on a continual basis
3. Inflammation begins to occur in the RTC muscle tendons.  This again occupies precious space between the humeral head and the AC process.
4. If the initial impingement syndrome is not addressed, the lubricating sack called the bursa then becomes irritated and swollen.  When this happens you now are dealing with shoulder bursitis (inflammation of the bursa) and impingement syndrome.  By now there is significant pain present even when the arm and shoulder are at rest

In summation:  RTC muscle weakness + Type of AC process + extra humeral head movement + onset of bursitis = A severe case of Shoulder Impingement Syndrome.

  

Symptoms Felt With Shoulder Impingement Syndrome

The initial symptoms felt with impingement syndrome are a pinching sensation on the front or lateral edge of the shoulder when reaching out away from your body, behind you, across your body, or when reaching overhead.  As the impingement syndrome worsens, the pinching pain can become very strong and begin to refer pain down the arm through one or all of the following muscles; the biceps, the triceps or posterior arm, or along the lateral aspect of the arm.  Typically symptoms of impingement syndrome do not refer past the elbow.  However this is not always the case.  This is why an evaluation of the cervical spine is performed as well.  The therapist wants to make sure that the referred pain into the upper arm and forearm are coming from the shoulder and not coming from the cervical spine.

What Causes Shoulder Impingement Syndrome?

This is not an easy question to answer.  Shoulder impingement syndrome can simply be caused by the type of AC process one has.  However, most shoulder impingement syndrome is caused simply through weakening of the RTC muscles.  The weakening then allows for improper movement of the humeral head in the socket.  Repetitive use is another way.  One might say though that they are used to working all day long lifting items of weight overhead or in front of oneself.  This thought of being strong through normal daily activity is usually the cause of impingement syndrome.  The most common cause of impingement syndrome is through overuse or repetitive use syndrome.  Just because you are using your arms in a physical manner doesn't mean that this is keeping the RTC muscles strong.  What is happening is that a person will think that they have strong shoulders because of the daily physical use.  Here's the downfall with this thinking.  "Daily use" is a normal daily activity.  And if this normal daily activity is performed in high repetition then the "daily" wear and tear on the shoulder will eventually become "too much daily activity".  The RTC muscles and tendons weaken and then the process of impingement syndrome sets in.

Other causes of impingement syndrome can be:

• Trauma
• Habitual posturing such as the position you might sleep in or sitting in your chair reading a book.  Habitual and prolonged posturing can cause decreased blood and oxygen supply to the RTC which causes weakness and allows impingement syndrome to set in
• Weakness of the shoulder itself such as the deltoids, triceps, and biceps muscles
• A compromised nerve in the cervical spine causing decreased motor signal impulses to reach the muscles of the shoulder and RTC
• Type of AC process
• And again of note, repetitive use or over use syndrome leading to shoulder girdle and RTC muscle weakness
• Specific sports that require a lot of overhead reaching such as tennis, swimming, or being a baseball pitcher.  These sports are very demanding on the shoulder.  If a proper strength regiment is not performed in addition to just playing these sports, then the likely hood of impingement syndrome setting in becomes high
• Age.  Getting older and loosing the elasticity in the soft tissues of the shoulder can cause excess joint play of the humeral head causing impingement syndrome

There are physical therapists that specialize in the treatment of shoulder injuries.  As previously stated, the shoulder is a very complex structure.  In this article, I have just glazed over in the simplest manner about the anatomy of the shoulder and the basics of shoulder impingement.  There are many primary nerves, arteries, and other vessels that are adjacent to the shoulder complex.  In order to isolate the cause of shoulder impingement, the therapist has to rule out pathologies of these adjacent tissues as well as the cervical spine.  It takes patience and compliancy with physical therapy to permanently overcome shoulder impingement syndrome.

In the meantime, enjoy reaching across the table for that last favorite delight!

Always In Good Health!

Brad Senska, PT, DPT, BS, ASTYM

bradsenska@yahoo.com 

Which Physical Therapy Practice Is The Best One To Go To?

The intention of this article is to help educate the patient on the different types of physical therapy practices and then how to decide which one is best for them

Choosing a physical therapist (PT) or physical therapy clinic is like choosing any primary healthcare provider.  Physical therapists are primary healthcare providers in most states now.  You also do not need a referral from a physician to attend physical therapy in most states.  Once you've decided on a PT, you'll most likely stick with this therapist for any subsequent injuries just like a primary care physician.  There are several types of PT practice models that operate in every state.  What I'd like to do is go through these practice models in order to help you decide on how to choose a PT if it ever comes to that for you. I'll then tell you the practice model that I really like and used in my PT practice.

There Are Three Types of Physical Therapy Practices

1. The Altruistic or Original Physical Therapy Practice
2. The High Volume Practice or Clinic
3. The "I Don't Know You" Practice or Clinic (This is my own label)

The Altruistic Or Original Physical Therapy Practice - Physical therapy initially began on a volunteer basis.  In the short of it, physical therapy initially got it's roots during the big polio outbreak several decades ago.  Physical therapy was initially administered by nurses or nursing aides (at that time called restorative aides) in order to restore motion to affected limbs of those suffering from polio.  By performing range of motion activities, this relieved extremity pain and restored, to a certain level, the function of the affected limb and the function of the patient.  Over the years physical therapy extended beyond just treating polio patients.  It was found that earlier movement after surgery provided better recovery outcomes.  Clinical and scientific studies began in depth and found that physical therapy provided much more to patients than one could imagine.  Physical therapy evolved to what it is today - a multi-disciplinary medical practice.  Physical therapy absolutely has it's place in patient care.  

I want to be as politically correct as possible but I also really need to inform you of the benefits of a original practice model.  Original practice models focus much more on the patient vs. how many patients a practice can get in the door (high volume practice & I don't know you practice) as well as their profit margin.  Yes, physical therapy is a business and practices need to make money.  However, patients should not suffer because of a greedy clinic owner.  With an original practice model, you will be the focus of attention.  You will be thoroughly educated with your injury, your plan of care, and what you should be doing and shouldn't be doing at home.  In addition, the therapist will spend a significant more amount of time with you.  You will have a very customized treatment and plan of care vs. a generic treatment at other practices.  The time you spend at physical therapy will be with a PT and not a physical therapy tech or other ancillary staff.  Another benefit of the original practice is that the PT will usually be much more thorough in their documentation with regards of how you are doing and with regards to communication with your physician if a physician referred you to physical therapy.  The bottom line is, the quality of care will be much greater than at other practice models.  

As previously stated, physical therapy is a business.  Physical therapists get paid from insurances just as medical doctors get paid from insurances.  But some physical therapy practices are more concerned about their profit margin (high volume practice) vs. a balance of proper care and profit margin.  This is where the original physical therapy practice once again comes in with high marks.    Ethical care takes priority.  The original physical therapy practice has a very nice balance between making money and giving the best care possible to the patient.  If a patient is able to find more of an altruistic practice model, then that person will see and feel a tremendous difference in patient care and see the difference with ethical billing practices.  However, for the Original clinic owner, keeping open appointments on the schedule becomes problematic due to the patients wanting to get in to the practice.  It doesn't take long for the Original practice model to develop a very good reputation.  It's this need to see patients that many clinic owners will adopt other practice models.  But good patient management, good time management, and adding a like minded PT to the practice can offset the need to morph in to a less ethical practice. 

Something that is very noteworthy and of great importance with an altruistic or Original PT clinic is that more responsibility is put on the patient with regards to compliancy with their treatment and plan of care.  This is because of the customization and Education that a patient receives in a Original practice.  The  Original PT practice is one that spends more time with a patient one on one.  This one on one time is to be able to educate the patient about their condition.  This isn't just a story telling time.  This information is meant for the patient to use during their recovery and be responsible for their recovery. If a patient is going to receive this kind of care then this patient needs to reciprocate and be responsible for their home care instructions.  However, being responsible with home care should be the case no matter the type of practice a patient goes to.  A patient should always follow through with the educational instruction from the physical therapist.    With other practice types, the so very important education of the patient is left out.  The patient goes through their physical therapy process without knowing why they are doing what they are doing.  So without further explanation here is an itemized list of the pro's for seeking out an altruistic or Original practice model:

• You will always see the same physical therapist
• You are held responsible for following the instructions by the PT for proper recovery.  Non-compliancy with this can mean discharge from physical therapy whether you have recovered or not.  Non-compliancy is often referred to as "waste of resource" by a patients insurance company if the patient is using insurance vs. cash paying patients
• Because you will always have the same therapist, problem solving of your injury is performed in a much more competent manner
• Your plan of care will remain consistent
• Progression of your care will occur at the right intervals and will be communicated in a timely manner to your referring physician
• Of great importance, you will be fully informed of all aspects of your injury and pathology.  So education regarding your care and recovery will be covered thoroughly
• This type of practice most often does not use ancillary staff such as PT techs, aides, or athletic trainers.  If ancillary staff are used, then they too will be educated fully on your plan of care.
• Discharge will be performed at the appropriate time.  
• The therapist does not see as many patients in a day as does a high volume clinic or an "I don't know you" clinic.  This results in better documentation and very ethical billing practices.  
• On the downside, these clinics are harder to get into.  Once you do get on the schedule it is up to you to maintain your schedule, limit deviation of your schedule time, and absolutely do not miss your appointments.  A good altruistic clinic is hard to find and often even harder to get into.  The best care comes from these clinics!

The original type of practice is absolutely my preferred method of practice.  Persons who do attend the high volume clinics do receive care that improves function and healing but the quality of the care is often questionable and of poorer quality.  So, if you ever have to attend physical therapy ask the clinic how many patients a therapist will see in a day.  If the number of patients exceeds 12 - 14 in a day, then you're looking at more of a high volume clinic and ancillary staff are most likely used.  Also make sure you will be seeing the same therapist each visit.  Clinics that treat patients with varying PT's are typically hospital based outpatient clinics and high volume clinics.  

The High Volume Clinic - The title already does a good job of describing this type of practice.  A high volume clinic is one in which a patient is seen more or less for just a few minutes by the PT.  Once the PT has checked in with you, you are then handed over to a PT tech, exercise physiologist, or an athletic trainer.  A high volume clinic is one that mostly benefits the owner of the clinic vs. benefitting the patient.  The more patients seen then the more money the clinic owner can claim in billing.  Often high volume billing practices are unethical.  

Education of the patient in a high volume clinic with regards to their injury or plan of care is minimal.  Because the PT comes and goes so quickly in a high volume clinic, the education of the patient is significantly bungled or left out all together.  What I mean by this is, the patient goes through the motions of physical therapy but they have no idea why they are doing what they're doing.  Nor does the patient get a thorough explanation of their pathology that brought them to PT in the first place.  

Next, with a high volume clinic, therapeutic exercises or activities are prescribed and then it is up to the PT aide or tech to perform these activities with the patient.  Once again, the PT aide is going through the motions with the patient but doesn't know exactly why the patient is performing a specific routine.  A huge downfall with this is that the tech doesn't know what signs or symptoms to look for that might be contraindicated for the patient.  The next thing to mention is, with a high volume clinic, prescribed exercise routines become the mainstream for everyone.  

Quick Editorial - Most times "filler" exercises are added to a routine just to keep a patient busy and  to accumulate time in the clinic.  These filler exercises are often not even related to the patient's injury.  They are added in order to accumulate the time you've spent in the clinic so that the clinic can bill you for this time.  

The mainstream exercise routines are because the PT doesn't have the time to customize a proper therapy protocol for a specific patient.  I have seen this first hand in several clinics and it ruins my whole concept of what physical therapy is supposed to be.  I have seen someone with a shoulder injury performing the same exercises and therapeutic activities that a patient with a total knee replacement is performing.  This does the patient no good at all.  It is also a very unethical practice.  Why would someone with a shoulder injury be performing exercises for their hip or knee?  Again, the answer to this is that the PT is too busy to customize and then educate the patient on a proper therapy protocol.  So instead of taking the time, the PT will hand the PT tech an generalized exercise flow sheet and have the tech perform this generic routine with the patient.  In addition to this, as the patient heals, the protocol needs to be changed or progressed in order to match the rate of healing of the patient.  With a high volume practice, the progression of a therapy protocol is not maintained.  Again, this leaves the patient in a "healing" limbo.  Of significant importance with this healing limbo, the patient's insurance only allows so many visits to physical therapy.  So each time the patient goes in to physical therapy, they are paying for something that is useless and something that the patient has a very poor chance at recuperating.    

Next, what happens when the patient has met the ability to perform the initially assigned therapy protocol?  They are usually discharged and are discharged prematurely.  The strength and function that was supposed to be acquired in order to go back to their regular work and recreational activities was not acquired.  This leaves the patient very susceptible and prone to subsequent injuries and poor long term healing.

As in typical fashion in my articles, I'd like to give you a simple summary of a high volume clinic:

• Minimal time is spent with the PT
• Proper education of the patient and the ancillary staff are not met
• A proper therapy protocol is often not met
• Proper progression of the therapy protocol is not kept up to date
• Unethical billing practices occur and this translates over to the patient paying for something they didn't receive
• The patient does not receive the care that they are paying for
• Discharge is often premature leaving the patient susceptible to unfinished healing or subsequent complication of the current healing
• There is poor documentation of the patients status.  Proper documentation is what dictates how much a clinic is reimbursed.
• Often unnecessary "filler" exercises are added to your physical therapy protocol so the clinic can justify the time you spent in the clinic and bill for that unnecessary time

The "I don't know you" clinic - This is a clinic in which is very similar to the high volume clinic except that the volume isn't with patients.  The volume is with PT's.  An "I don't know you" clinic is one in which a person has a different therapist each time a they go in for a physical therapy treatment.  The patient is usually not informed at the time of scheduling that they will not be seeing the same therapist on a subsequent visit.  Imagine that you chose a primary care doctor.  When you go to the doctors office you know that you'll be seeing the doctor that you were expecting to see.  By seeing the same doctor you're able to build a relationship with the doctor.  By doing so, the doctor gets to know you well and is able to meet your needs in a very specialized way and in a very consistent way.  A relationship with confidence and trust is built.  This is the same way that physical therapy in my opinion should be practiced as well.  However, many clinics do not do this.  Instead, the patient is often placed on the schedule just to get you back in the door for your next visit at the clinic's convenience, not yours.  When you're placed on the schedule, you're also put with a different PT.  Here is an example.  A patient has been coming in at 10:00AM Monday, Wednesday, and Friday for the past 2 weeks.  Now all of a sudden for some reason, this time slot that they are used to is taken after two weeks out.  However, there is an option for the patient to stay with the current PT.  This is to schedule with the same therapist but at a different time.  But often times, the scheduling staff will keep you at the same time so that the rest of the schedule is not upset and when they do so the patient is scheduled with a different therapist.  In many cases, the patient will see a different therapist each subsequent visit.  This "I don't know you" method also benefits the clinic or clinic owner vs. accommodating the patient.  

The downfall of seeing a different PT each visit is quite obvious.  As with a patient's primary care doctor, a relationship is built.  Doctor and patient get to know each other and become comfortable with each other.  Same as with seeing a PT, trust and confidence are built as is a good plan of care for the patient.  Patient education is established with the PT, consistency with treatment is maintained with your PT, and good communication is established between you, your PT, and your referring physician.  When a new PT is tossed into the mix, it's like going to see a stranger and your plan of care is disrupted.  In addition, the PT does not know you or your status and your plan of care again is disrupted even further.

Here is a summarized list of con's with seeing an "I don't know you" clinic:

• Most importantly, a patient's plan of care can be disrupted
• Poor consistency of treatment
• There is a chance of multiple diagnoses and change in philosophy of treatment
• Education of ancillary staff regarding the patient is poor
• Mixed educational messages often occur due to a PT's philosophy of practice
• The patient's treatment can suffer due to the PT not having the full history of the patient prior to treatment
• Of the different PT's, who will decide the progression of treatment and who will decide the appropriate discharge date?
• Often unnecessary "filler" exercises are added to your physical therapy protocol so the clinic can justify the time you spent in the clinic and bill for that unnecessary time

My advice to you is to insist on the same therapist from each treatment session to the next!

Here is what you will want to know and ask when attending physical therapy:

• Will I be seeing the same therapist each session?
• How much time will my therapist spend with me?
• Will I be under the care of physical therapy techs or aides during my treatment?
• What part of treatment will the ancillary staff (PT techs, PT aides) be administering?
• Ask to be scheduled out as far as possible so that you can stay with the same therapist and keep your therapy consistent
• Pay attention to how much time you spend at your physical therapy clinic.  Then make sure that your bill matches the amount of time spent during your PT treatment.  Often times there is over billing.  Insurance companies do not have nearly enough time or manpower to audit physical therapy practices or medical practices in general 

On another page in my website, I mention that physical therapists do specialize in specific treatments or pathologies.  This is something else you will want to consider when choosing a clinic.  You will want to inquire about whether or not the clinic in question treats your specific injury.

As Usual, Good Health & Spirits To All

Brad Senska, PT, DPT, BS, ASTYM.

bradsenska@yahoo.com

When Is The Best Time To Eat In An Endurance Event?

I believe this article will help most with people of whom are just getting started with their adventure in endurance sports.  I've not ever discussed nutrition in my blog and there's a reason for this.  The intake of nutrients during an endurance event is different for each individual person.  Nutrition is very customized.  A person will go through a period of trial and error with several different types of energy gels and bars before settling on one or two that work best for them.  So what I'm going to do in this post is give you the basic breakdown of the different types of nutrients or fuel that is used during a endurance event.

Fuel intake during endurance events seemed to become of strong interest in the early 80's.  The default fuel intake during this time were bananas.  Why bananas?  Bananas contained essential electrolytes and the right type of sugar that could be quickly converted to the appropriate type of fuel for the muscles without disrupting the gastrointestinal (GI) system during high physical output.  This was great!  The problem however was that the energy the banana supplied was short lived.  In addition, carrying enough bananas with you during a long event wasn't practical.  So what was needed was a compact lightweight fuel that would provide a person with enough energy for a sustained period of time and a fuel that didn't disrupt the GI system.  Another consideration for the right type of fuel is one that wouldn't pull too much blood from the working muscles to the stomach in order to breakdown and digest the fuel.  So what did the researchers come up with?  Here's the answer:

"Monosaccharides and Disaccharides" along with other nutrients such as electrolytes, anti-oxidants, amino acids or proteins, caffeine, vitamins, and flavoring.  Each energy company has their own secret recipe.  Because of the varying ingredients from one gel to the next is the reason why a person may have to go through a trial and error of which gel is the best one.  One gel may have too high of a concentrate of one or another sugar or caffeine for a particular person's digestive system.  Using a gel or bar that doesn't get along with your digestive system can cause cramping, diarrhea, and the inability to absorb any type of nutrient because of the current digestive system upset.

Monosaccharide and disaccharide?  What the heck are these?  No worries.  They are just fancy names for sugars that we consume in our everyday foods.  Let's start with a monosaccharide.

Monosaccharide (one sugar by itself):  This would be the same thing as glucose or dextrose.  This is a single molecule sugar.  Single molecule sugars breakdown in to useable energy very quickly and is very easy on  the GI system.  Glucose is the sugar that our muscles and brain use as energy.  This sugar is the most easily digested sugar and is most readily available.  

Disaccharide (two sugars bonded together):  Fructose is a disaccharide.  A disaccharide is a two molecule sugar and therefore slower to break down into useable energy.  Fructose is a sugar that is found in fruits and vegetables.

Maltodextrin:  This is the most common sugar found in energy gels.  Maltodextrin is a more complex sugar because it is made up of more than one or two molecules.  Maltodextrin breaks down in an optimum manner to provide you with the right flow of fuel or energy to the bloodstream without disrupting the GI system.  

Sucrose:  This too is a disaccharide.  This molecule is made up of one glucose molecule and one fructose molecule.

There are other sugars used in energy gels and bars but the above listed are the most common.  You notice how I just breezed over the names and definitions.  To say more about them would be getting into the chemistry of each and this can become complicated.  Here's an example of the chemistry and considerations when creating an energy gel:

• If you noticed, sucrose is a disaccharide (glucose + fructose).
• Glucose by itself is a monosaccharide.  Same as fructose.    
• Maltodextrin is varying lengths of glucose chains, i.e. glucose + glucose + glucose... up to ten or more molecules combined together.  When many sugar molecules are bonded together then the sugar becomes a polysaccharide.  These too are used in energy gels and bars for sustained energy release.  The more bonds in a sugar chain that need to be broken down, then the slower the release of energy into your system.
• But in any gel or bar, the main ingredients will be a combination of sucrose, glucose, fructose, and maltodextrin.

Energy gel and energy bar manufacturers go through a tremendous amount of combinations of these sugars as well as vitamins, amino acids, electrolytes, etc. so as to get the energy gel or bar just right.

What Does "Just Right" Mean?

Just right means that the gel will absorb at just the right rate and release just the right amount of energy to keep the GI system working just right.  The sugars listed above are simple and not complex sugars that break down in the stomach and are either absorbed via the stomach or as they just enter the small intestine.  If the gel or bar contained a more complex sugar then it would take longer to be absorbed, require more blood to be pulled from the working muscles, and could cause an upset stomach as well as muscle cramping.

So, When is the best time to ingest the energy gel or bar?

This really is the question now isn't it?  Now that the gel has been properly formulated, when is the best time to consume the gel?  Most manufacturers give a general guideline of when and how to consume the gel.  The general guideline is 15 minutes prior to your activity and then 45 minutes to one hour after you've begun your exercise and then every 45 minutes until you've completed your exercise.  Remember, this is a general guideline.  This absolutely does not work across the board for everyone.  Each person burns through calories and fuel at a different rate as they exercise.  However, this is the link as to when it's best to consume a bar or gel.  

Exercise exertion plays a big factor in the timing of when to consume an energy gel.  Your fitness level also plays a role in when to consume an energy gel.  Generally, the more trained and conditioned you are, then you have greater lee way of when to consume a gel and how much you need to or are able to consume.

Fitness level aside, physical exertion or the intensity of the exertion is the factor on when to consume energy fuel.  The intensity of work being done will determine how well and how quickly the energy will be absorbed and then used by your body.  This is one of those factors that fall into the trial and error category.  To get straight to the point, it's best to consume energy gels/bars when you are not exercising or racing at a high intensity.  If you've ever watched professional cycling, the feed zones are usually placed along the course in which the cyclists are not cycling at their highest intensity.  There is a reason for this.  When exercising at a high intensity, blood and oxygen are diverted into the working muscles.  When you consume an energy gel, blood is called away from the working muscles to the stomach in order to digest the gel or bar.  The amount of blood that is diverted is also relative to how much of the gel or bar is consumed and how dense the nutrients are in the fuel.  If too much energy fuel is consumed at one time this can cause GI distress and even muscle cramping.  This is one reason why energy gels come in small packets.  Gels are meant to be taken in smaller amounts so that GI distress does not occur.  

There are several reasons why energy gels and bars are designed the way they are.  And I'm not talking about the shape or size of the energy fuel.  I'm talking about the chemistry of the energy fuel.  Here are the most important reasons.  They are designed:

• To be digested with minimal blood being diverted from the working muscles to the stomach
• To be absorbed by your digestive system as easily as possible and as quickly as possible
• To not create a blood sugar spike and then low.  This is where the "chemistry" of energy gels really come into play.  Energy gels need to release energy into the blood stream in a even and fluid manner.  If too much sugar and electrolytes are released to quickly, then the possibility of GI distress becomes a risk.
• To release the right amount of energy over a designated period of time.  This is where monosaccharides, disaccharides, and polysaccharides come into play.  The longer the sugar chain is, then the longer it takes to digest.  However, the long chain sugars will provide energy over a longer period of time.  A good example of a longer releasing energy fuel would be a Power Bar or Cliff Bar.

In summary, an energy gel or bar is best taken when not exercising or racing at your highest intensity.  It's also best to consume several ounces of water with the gel or bar to aide in proper digestion.  Energy bars and gels are created for specific purposes so read the labels and make sure you are consuming the proper gel or bar for the specific activity that you are performing and at what intensity.  Personally, I don't feel I've done this article justice.  There is a lot to consider when fueling up during high intensity activity.  As previously stated, it takes a period of trial and error to get the right energy fuel that works best for you.  Some gels are much more concentrated than others.  Some contain high amounts of caffeine and others high amounts of electrolytes.  Often, more than just one specific gel is consumed so that all bases are covered during training or competition.  

As usual, if you have any questions, thoughts or concerns, please feel free to contact me.  In the mean time, Bon Appetite!


Brad Senska, PT, DPT, BS, ASTYM.
bradsenska@yahoo.com