Archive for February, 2010

The Hampering Hamstring

by G. John Mullen, DPT 2011 |

Fantasy baseball drafts and spring training are in the air…you can almost smell the finely cut grass, taste the $10 hot dogs and feel the $20 beer in your hand.  At the same time, the beginning of the season comes with big question marks hanging over the heads of players with injuries: Tommy John surgery, alcohol related rehabilitation, and hamstring strains (aka “pulling a hammie”) to name a few.  Most regular folk have experienced a hamstring strain and know it does not get better without a fight and a bottle of Georgia Moon (maybe not the later for everyone).   Before we get into treatment lets hit the basics of the hamstring.

Stat Fact: One-third of hamstring strains will recur with the highest risk of recurrence occurring 2 weeks after the initial injury.

Getting to Know Your Hammies

The hamstring is the predominant muscle in the back of your thigh.  The hamstring is composed of three muscles (biceps femoris, semimembranosus, semitendinosis…in case you were wondering) and their primary collective action is to flex the knee.  The most common cause of a hamstring strain is from the “eccentric use of the hamstring” while running. The eccentric use of the hamstring is highest when your leg is extending, off the ground, and swinging forward prior to hitting the ground for your next step.  This stage is termed the “terminal swing” (and yes, we realize this sounds more like a carnival ride than a leg movement).  The eccentric load is highest due to the amount of stretch it places on the hamstring muscles (this is similar to the strain you feel in a straight leg raise).

How do you know if you’ve hurt your hamstring?

Hamstring injury usually presents with a pop, pain in the back of the leg and decreased strength and range of motion.  The strain can occur in any of the three hamstring muscles at any point in the muscle, but the most common site for a strain is either behind the knee or near the butt.  Hamstring strains are classified by the amount of pain, weakness and loss of range of motion associated with the injury.  They are commonly graded on a 1-3 scale with I being mild, II is moderate and III is severe.  The duration of the injury depends on the site and size of the injury.  If you have a large tear near your butt, you’re what we physical therapists call “pretty screwed.”

Stat Fact: The attachment of the biceps femoris is at the outside of the knee (where the complete tear is identified in the picture above).  This particular region is the most commonly strained part of the hamstring muscles because it undergoes the highest amount of stretch amongst the hamstring posse.

Hamstring Hangover

The goal of rehabilitation is to return the athlete to their prior level of performance while minimizing the risk of injury recurrence.  Multiple factors contribute to a high re-injury risk of the hamstring: (1) persistent weakness in the injured muscle, (2) reduced flexibility due to scar tissue, (3) impaired movement/biomechanics due to injury.  Strengthening the hamstring is a fundamental component of rehabilitation and needs to include eccentric (muscle lengthening) and concentric (muscle shortening) exercises.  In addition to strengthening your hamstrings, the muscles attached to the pelvis are often weak and require assessment and strengthening. Rehabilitation of grade I and II hamstring strains can be broken into three distinct phases:

Phase I:

The goal of the Phase I is to decrease swelling, pain and scar tissue formation. You should avoid excessive stretching of the hamstring in this phase since over stretching can increase scar tissue formation. To avoid over stretching, limit your knee flexion range of motion by taking shorter strides while walking or using of crutches.  Ice should be used 2-3 times per day for 15-20 minutes with an ice pack to decrease swelling and pain (no more than 15 minutes at a time as longer amounts of time may increase swelling).  Exercises in Phase I should not stress the injury site. The most common exercises prescribed during this phase are single leg balance (seen in the picture to the left), isometric abdominal exercises, and lateral stepping drills (grapevine/karaoke).  Advancement from the first stage of rehabilitation includes normal walking and stride length without pain, light jogging without pain, and a lack of pain while resistance is applied with the knee bent to 90 degrees (lay on your stomach with your knees bent to 90 degrees and have someone gently pull your ankle down to the floor…pain = no good). Phase I is typically 5 days long but as doctors love to specify that “it depends.”  It always depends.

Phase II:

The goal of Phase II is to increase intensity of exercises, increase range of motion and to begin eccentric exercises. Ice is typically used after training to decrease pain and inflammation associated with exercises.   In Phase II exercises, we increase speed and intensity of agility drills.  Side to side agility drills should be utilized to decrease the risk of overstretching the muscle.  At the end of Phase II, you can progress agility and strengthening drills to include forward and backward movements (supine bent knee bridge walk-outs…Google it).  Eccentric strengthening is initiated and incorporated as functional movements (light jogging, moderate high knees) instead of isolation exercises.  To progress to Phase III, the participant must be able to 1) pull with the full strength of your hamstring against resistance with your knee bent to 90 degrees and 2) forward and backward jogging at 50% of maximum speed without pain. Phase II typically last 1-2 weeks.

Stat Fact: Mobilization (lengthening) of skeletal muscle 5-7 days after injury can enhance fiber regeneration.

Phase III:

Phase III involves sport specific movements with no range of motion restrictions but sprinting and high accelerations should be avoided until return-to sport-criteria are met.  Ice should be used as needed after rehabilitation exercises.  Exercises in Phase III involve sport-specific exercises emphasizing quick direction changes and proper technique.  Trunk stabilization should be improved with movements in multiple planes of motion. Single leg bridges and single limb windmills (see picture) are examples of high intensity exercises.  In order to be cleared to return to the sports you need full range of motion, strength and functional abilities (cutting, running, jumping). Phase III usually lasts 1-2 weeks.  The total time for hamstring recovery is typically 3-5 weeks.


To prevent hamstring strain, we recommend a combination of stretching and strengthening exercises. Research studies have not shown any significant benefit to stretching your hamstrings therefore static hamstring stretching is not the best prevention tip.  However, scientists believe that an improper length of the quadriceps and hip flexors are a risk factor for hamstring strains.  Therefore, increasing flexibility of these muscles is mandatory to prevent hamstring strains.  Additionally, research showed that eccentric hamstring training prevents strains.  Eccentric hamstring training should be incorporated into a preseason and in-season training program for all athletes at risk for hamstring injuries.  An exercise routine for eccentric hamstring training can include Romanian dead lifts, knee fall downs and single leg Romanian dead lifts (see picture above). Lastly, exercises that incorporate the lower extremities and pelvis are associated with a decreased risk of hamstring strains.  Examples of these exercises include high knee marching, forward-falling running drills, and explosive starts.


Prevention is the key here!  Make sure warm-up for 10-15 minutes (and by “warm-up” we mean activity that raises your heart rate and gets you sweating) before any work out.  Incorporating a proper warm-up, eccentric hamstring training and proper hip flexor and quadriceps muscle length will decrease your chance of the ending up with a hampering hamstring.  Everyone wins!

Questions?  E-mail G. John Mullen:


1. Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. Feb 2010;40(2):67-81.


02 2010

Prevent Jet Lag: Who wants to be tired on vacation?

by Kelly Erickson, MD 2010 |

Sleeping on the PlaneWith record-breaking storms keeping many Americans trapped indoors this winter, it is hard to imagine that summer will ever come.  Daydreaming about your spring getaway or summer vacation to Europe may be your only respite from the cold.  But when you consider vacation, especially one that takes you multiple time zones away from home, one of the major drawbacks is coping with the even harsher reality of “jet lag”.  Whether it requires you to sleep when you arrive at your destination rather than enjoying immediate exploration or demands that you take yet another day off from work once you return home, jet lag is undeniably inconvenient.  Here we will explain the causes of jet lag and how to best prevent it from hindering your well-deserved adventures.

What is jet lag?

According to a recently published article in The New England Journal of Medicine, jet lag is a “recognized sleep disorder that results from crossing time zones too rapidly for the circadian clock to keep pace.”  It is a constellation of symptoms that can Jet Laginclude insomnia, daytime sleepiness, fatigue, poor physical performance, cognitive impairment and gastrointestinal changes.  What the scientists meant to say was that you are going to feel lousy.   Jet lag is most commonly experienced after crossing at least 5 or 6 time zones (the East Coast-West Coast trip doesn’t apply here!).  Jet lag is most commonly confused with “travel fatigue”, which is the unfortunate result of the combination of sleep deprivation, stress caused by traveling, diet changes, etc.  While travel fatigue can be easily treated with a little rest and T.L.C., jetlag is a horse of a different color.

How does this “jet lag” nonsense happen?

The body’s circadian clock is located in the suprachiasmatic nucleus (SCN) of the hypothalamus (imagine a point directly between your eyes and two inches towards the back of your head…eureka, you’ve found it!).  It communicates with the retina, allowing it to sense light and dark.  Suprachiasmatic NucleusBased upon our regularly predictable cycle of waking and sleeping, the SCN promotes alertness or sleepiness in sync with our daily routine by regulating the secretion of melatonin from the pineal gland.  The system works such that light inhibits the secretion of melatonin.  Therefore, melatonin has often been referred to as the “dark hormone”, because it is only secreted when there is no stimulation by external light (aka nighttime).  The problem with this system is that our circadian clock does not adapt quickly to changes in the cycle (i.e. flying half-way around the world in single day).  Therefore, in the same way that “motion sickness” is the result of desynchronization between visual and spatial stimuli in the setting of movement (didn’t know that, did you?), jet lag is the body’s response to the imbalance between a predicted sleep-wake cycle and a change in external light and dark stimuli.

How to Beat It:

1.  Re-sync your clock. This is accomplished with 2 strategies.

  • Timing of Light Exposure: Based on what we now know about the circadian clock, we now understand how light can be used as a powerful tool to “trick” the circadian clock and therefore advance or delay it.  Although it may seem logical to think that sleep itself resets the clock, it is actually exposure to light and dark that is most effective.  What does this mean?  Studies have shown that light exposure should be used as follows after travel. Eastward travel: Upon arrival seek exposure to bright light in the morning.  This will help delay your circadian clock.  Westward travel: Seek exposure to bright light in the evening, which will help advance your circadian clock.

  • Taking Melatonin:  Because light inhibits melatonin secretion, recommendations for Melatoninmelatonin are the opposite of those for light exposure.  When melatonin is taken in the evening, it resets the body clock to an earlier time and when taken in the morning, it causes the clock to be set to a later time.  Guidelines for melatonin use are, once again, broken down depending upon the direction of travel.  Eastward travel: Take 0.5mg-3mg at bedtime to shift your circadian clock to an earlier time and help you fall asleep.  Westward travel: Take 0.5mg during the second half of the night to shift circadian clock to later time and allow you to continue to sleep.  When traveling westward, the most common sleep disturbance is difficulty staying asleep.  Therefore, melatonin should be taken after awaking in the middle of the night in your new time zone.


2. Plan out your ZZZZZ’s. When planning a trip, you buy your airlines tickets in advance, purchase your travel books and research all of the best sites to visit.  Why not spend a few extra hours sleeping before you leave to help ease the jetlag when you arrive?  More sleep plus less jet lag sounds like a good deal to us.  In general, this means shifting the timing of your sleep 1-2 hours earlier for a few days before eastward travel and 1-2 hours later for a few days before westward travel.

3. Medication. When all else fails, manage your symptoms with some good old-fashion meds.

  • Downers (aka sleeping pills):  Studies have shown that 10mg zolpidem at bedtime helps patients get a good night’s rest after long-distance travel and helps to reduce the symptoms of jet lag.  It’s best if you give the medication a test-run before you leave to ensure that you do not have any unwanted side effects while in the safety of your home country (amnesia and confusion…not so fun in a new city where you don’t speak the language).

  • Uppers: Caffeine, while generally discouraged for those attempting to overcome jetlag, can be used in small doses early in the day to increase daytime alertness and decrease sleepiness.  Small doses for those of you who missed that part the first time.

The Take Home Message: Jet lag sucks (as the scientists so eloquently explained) but can be mitigated with some planning, preemptive measures before you leave home, and a little proactive management once you’re on the ground in your exotic location of choice (our advice: print out this article so you can remember all these tips when it’s go time).  There’s no reason to feel like poop during your valuable travel time.  Vacation, here we come.  Now get packing!

Questions?  E-mail the author: Kelly Erickson, MD 2010 |

Bora Bora, French Polynesia


1.  Sack, Robert L.  Jet Lag.  The New England Journal of Medicine 2010; 362:440-7.

2.  Herxheimer, A., Sanders, M., Mahowald, M., Sokol, H.N., Jet Lag. UpToDate, 2010.

3.  Herxheimer, A, Petrie, KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev 2002; :CD001520.

4.  Jamieson, AO, Zammit, GK, Rosenberg, RS, et al. Zolpidem reduces the sleep disturbance of jet lag. Sleep Med 2001; 2:423.

5.  Morris HH, 3rd, Estes, ML. Traveler’s amnesia. Transient global amnesia secondary to triazolam. JAMA 1987; 258:945.


02 2010

Tendon Injuries: Getting Back to Go

by G. John Mullen, DPT 2011 |

With the Vancouver Winter Olympics in full swing, tendon injury is a hot topic on news channels across the globe.  Sports fans from every nation will be cheering on their favorite athletes and crossing their fingers for speedy recoveries from accidents Olympic Speed Skaterincurred during the intense competition in the coming weeks.  Shoulder pain, elbow pain, ankle pain?  These joints are common sources of pain for professional athletes and law-abiding citizens alike.  Whether you have golfer’s elbow, tennis elbow, speed skater’s knee, shoulder impingement, jumper’s knee, Achilles tendon pain, you are suffering from a “tendinopathy.”  Tendons, which connect muscles to bones, are composed of collagen.  Tendinitis is the most common term associated with tendinopathy. Tendinitis is the acute injury of a tendon and is typically associated with inflammation (note that “-itis” means inflammation). Tendinosis is a term used less commonly but refers to the process in which tendinitis becomes chronic (lasting greater than 3 weeks). To understand the disease of tendinopathy, it is essential to understand the design of a tendon, common causes, treatments for the different types of tendinopathies and what you can do to prevent these disorders.

Stat Fact: The prevalence of Achilles tendinosis has been estimated to be between 11% and 24% in runners, whereas the prevalence rate for patellar tendinosis in basketball and volleyball players has been recorded as high as 32% and 45%, respectively4.  That’s a lot of tendon inflammation.

Tendon Architecture

As we mentioned earlier, the tendon is primarily composed of collagen, more specifically type I collagen (there are 29 different types of collagen in the body but 4 main types make up 90% of our collagen).  Tendon tissue has a poor blood supply (only 1/3 Achilles Tendonof the blood supply that muscles have) which means that it takes tendons notably longer than muscles to heal.  Following an acute injury, the tendon strained becomes inflamed (filled with cells trying to repair the tissue).  After chronic use of the tendon, type III collagen becomes predominant.  This change in collagen will make the tendon larger due to increased collagen rather than from inflammation.   Along with the increase in collagen comes an increase in water in the tendon as well.  These two changes make the tendon thicker which you notice as increased stiffness.  At the same time, the tendon becomes more compliant leading to an increased rate of tendon strain after a chronic tendon injury.  Cadaveric studies suggest after a chronic tendon injury, the strain increases causing a decrease in stiffness and strength.  Strain is “the amount of displacement with an external load placed on the object” or, in the cadaveric study, “the amount of displacement increased after injury.”  Essentially, it means the amount of laxity (“looseness”) in the tendon after injury.

Common Causes

The majority of tendinopathies are due to overuse and are caused by such activities as:

  • Rapid increase in usage (New Year resolutions…)

  • Not warming up properly

  • Changes in footwear (for lower extremity tendinopathies)

  • Weak surrounding muscles

  • Improper muscle length or flexibility

Stat Fact: Achilles tendinopathy is a common overuse injury, accounting for 11% of all running injuries2.

Tendinitis Treatment

Tendinitis is an acute tendon injury associated with inflammation. Tendinitis is caused by an accident that causes damage to the tendon or chronic use leading to tendon irritation.  The length of this inflammation is variable, therefore the term tendinopathy is used to classify all the tendon injuries Icing a Knee Injury(you know doctors don’t like to put timelines on healing!).  The majority of treatment for tendinitis consists of anti-inflammatory medication or a cortisone shot (used only in extreme situations) administered by the physician.  The list of anti-inflammatory drugs is extensive, including as Ibuprofen, Motrin, Naproxen, Celebrex, and many more.  Physical therapists can help reduce inflammation with a number of treatment modalities (electrical stimulation, low level laser therapy, ultrasound, ice) that can decrease pain and inflammation.  The last and the most important treatment for tendinitis is a temporary discontinuation of the activity that caused this inflammation.  As stated, true tendinitis is from an acute accident therefore discontinuing that activity while the tendon heals makes sense…let’s agree to agree on this one.

Tendinosis Treatment

Treatment of tendinosis is more researched than the tendinitis.  In general, injuries that present to physical therapy and primary care doctors are tendinoses.  Remember, tendinosis develops from long-standing tendinitis and is often mistaken for tendinitis due to the increase in tendon size.  However, this increase is size is due to remodelling of collagen as opposed to the inflammation we see in tendinitis.  Recent studies show that exercise is beneficial for healing tendinosis.  More specifically, eccentric overload training appears to have optimal results.  What is “eccentric overload training”, you ask?  An eccentric exercise is an exercise that lengthens a muscle.  For example, Eccentric Overload Training - Calf Raisesif you are performing a squat, lowering your body down is the eccentric phase of the exercise on your thighs and returning to the start position is the concentric phase for your thighs.  Overload eccentric exercise training studies suggest eccentric training increases stiffness of the tendon and help change the tendon back to type I collagen.  Increasing the tendon stiffness provides the support your muscles need to contract so that it can maintain the muscle in the position where it produces the most force.  Let’s look at another example:  Achiles tendinitis is common in runners.  Mix in a little hard headedness and a desire to keep running despite injury and you have yourself the perfect storm for the development of a tendinosis.   To treat this population of patients, a 12-week exercise program consisting of heel drops has shown excellent results.  This program uses high repetitions of the exercise: 3 sets of 15 repetitions two times a day with progressively increasing external weight (you can add weight to backpack that you wear during the exercise)1. One key during this exercise is to only perform the eccentric phase of the heel drop with your injured leg.  To do this, slowly lower yourself down on the injured leg (the eccentric phase) and then return to your tippy toes by concentrically using the healthy leg.  This type of eccentric exercise can be used in any type of tendinosis.

Stat Fact: In the study mentioned, participants noted a decrease in pain from an average of 81/100 to 5/100 where 0 represents no pain1.

Double Stat Fact: Studies suggest that eccentric exercise can change tendon stiffness from a 14% loss in stiffness to a 10% gain in 14 weeks3.

Preventing Tendinopathy

Many times tendinopathies can be prevented with proper warm-up and progression of exercise.  Include proper stretching and eccentric muscle training to muscles at risk for your activity and you will have created an adequate prevention program.

Examples of eccentric exercises for common tendinopathies:Heel Drop

Heel drop for Achilles Tendinopathy:

Begin with your foot on a surface that allows your heel to drop below the height of your foot, while holding onto a handrail, banister or child (ok, maybe not a child) lower yourself slowly on the injured leg.  Push yourself back up on your non-injured leg.

Theraband ankle inversion for Posterior Tibialis Tendinopathy:

Ankle InversionBegin in a sitting position and put loop theraband (an thick elastic band) in which the loop is on the inside of your foot.  Move your foot down and in without resistance and then attach the theraband around the foot with high tension.  In a controlled manner, allow the foot return to the up and out position.

Wrist Extension and Flexion for Golfer’s and Tennis Elbow

Begin in a sitting position and allow your elbow to rest on your thigh.  For tennis elbow, begin with your hand facing the floor, with a weight in your hand.  Slowly lower the weight and then use the other hand to bring the weight back up to the starting position.  For golfer’s elbow, begin in the same starting position, but with your hand facing the ceiling and then lower the weight to the floor.

Wrist Flexion & Extension

Rehab Recommendations:

During recovery, the following recommendations should be followed for all eccentric exercises2:

  • 3 sets of 15 repetitions

  • Slow, controlled movements

  • Exercise should elicit a moderate amount of pain

  • Passive return to starting position with assistance from the non-injured side

  • Increase load when pain is minimal or absent

  • Perform exercises twice a day

  • Avoid aggravating activities for 4-6 weeks during eccentric rehabilitation



1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med.26(3):360-366.

2. Chang H, Burke A, Glass R. JAMA patient page. Achilles tendinopathy. JAMA. Jan 2010;303(2):188.

3. Narici M, Maganaris C. Adaptability of elderly human muscles and tendons to increased loading. J Anat. Apr 2006;208(4):433-443.

4. Wasielewski N, Kotsko K. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train.42(3):409-421.


02 2010

Cold Sores: Stopping Them Before They Start

by Tania Houspain, PharmD 2011 |

It is freezing cold outside, you’re stressed out about finals, and now your good old friend, Herpie (your favorite cold sore), is back.   You and Herpie have been friends for a while now.  You met him at a party in college when you didn’t think it would hurt to share Paris Hilton with a Cold Soredrinks with the guy with the weird bump on his lip.  College is, after all, the time for bad decisions.  You live and you learn.  Now you are so paranoid that you won’t even share a cup with your own mother.  Sadly, though, it’s too late.  You and Herpie have begun an unavoidable lifelong relationship, a relationship that people all over the world are stuck with (note Paris Hilton’s sexy, lip gloss-coated cold sore).  With the medical treatments we have today, there’s nothing you can do to stop cold sores from coming back.  There are, however, a few things you can do to minimize number of cold sores you get and potentially shorten the length of time those annoying cold sores stick around.  Now let’s see if any of the current treatments are good enough to prevent a cold sore.

What causes a cold sore?

Herpes Simplex Virus StructureCold sores are caused by a virus called the herpes simplex virus type 1 (HSV1). Yes, I said herpes.  When most people hear herpes they think of the sexually transmitted infection that causes sores in the nether regions (genital herpes) and they’d be right. Most cases of genital herpes are caused by herpes simplex virus type 2 (HSV2) while most cold sores are cause by HSV1 but both viruses can (although much less common) cause sores in the opposite region if the active virus comes in contact with that region (use your imagination here).

How do you “catch” a cold sore?

When you “catch” a cold sore you’re catching a virus.  Viruses are much smaller than bacteria and live inside your cells.  When someone has a cold sore it is caused by the herpes virus in the cells of their lips making a bunch of copies of themselves eventually causing the cells to burst open.  When the cell bursts, it frees the viral particles allowing them to invade more cells and repeat the cycle.  When enough of your cells are burst you get Herpes Outbreakthat wonderful oozing area of cells referred to as a cold sore.  Most people can see some redness, feel itchiness and pain over the area in which they are about to get a cold sore. This is caused by the death of your cells in that region.

So where did you get the initial virus?  You can get it anytime you exchange fluids with someone who is infected with the herpes virus and is actively shedding the virus.   Activities like kissing, sharing a cup, sharing utensils, toothbrush, etc.  Cold sores are most contagious when someone has an open blister present on their lips until the point where the blister has completely healed.  At the same time, note that certain people can spread the virus through their saliva even if there is no open blister present.  Maybe hold off on kissing a lot of frogs until you meet prince charming?  We’ll leave that one up to you.

Ok, so why is there no cure for herpes?

That’s like asking why there isn’t a cure for the common cold (also caused by a virus, though not a herpes virus).  Viruses are pesky like that.  Herpes, in particular, has the ability to travel deep into your body and make a home for itself in your nerve fibers.  Once the virus reaches your nerves, it temporarily goes into stealth mode, waiting for the opportune time to resurface.  During this time, the elusive little buggers hide from your immune system and medications.  This is called “Latency” (as seen in the diagram below depicting the virus moving from the epithelial on your lip to your nerve cell where it will lay dormant).  Herpes then rears its ugly head when your immune system gets weaker or is preoccupied with another infection.   It’s like guerilla warfare.  That’s why most people get another cold sore (called “reactivation” of the virus) when they get sick, are stressed out, or are just generally not taking good care of themselves.  Sun damage has also been linked to cold sore outbreaks (so if you find that’s one of your personal triggers, try using a chap stick with at least SPF 15).


Now to the fun stuff: products that may help quickly get rid of or prevent a cold sore that you can find at your local pharmacy and don’t need a prescription to get.

Abreva  (active ingredient: Docosonal)

How it works:  It changes the cell membranes of healthy, uninfected cells. These changes help prevent the cold sore virus from Abrevagetting into healthy cells so the viral particles can’t spread to new cells. Think of it as dead bolt and home security system for the doors into your healthy cells.

Does it work?:  Yes!  It doesn’t prevent a cold sore but if you start using it as soon as you think you’re getting a cold sore it will shorten the amount of time you have to spend with Herpie.  On average, Abreva shortens the cold sore’s stay by 3 days (so if your cold sore usually hangs around for 7 days it’ll be gone by day 3 if you use Abreva at the first sign of it…remember that initial itching/tingling sensation?).

How to use it:  It comes in a cream and spray that you apply onto the cold sore.  You’re supposed to start applying it at the first signs of a cold (so any redness, tingling, itching, etc near your lips. If you’ve ever had a cold sore you can probably tell your going to get one soon).  If you wait until the blister is fully formed, Abreva will still help but it won’t be as effective as it is if you use it right away.

Note:  This is the only FDA approved drug to shorten the duration of cold sores and speed healing time (when you hear FDA approval you can rest assured that its been thoroughly tested for safety and efficacy before being sold to you).  The rest of the treatments that can be found in your pharmacy have some supporting research but no FDA approval just yet.

Cost:  $18 for each 2-gram tube. Each tube last from 2-3 outbreaks depending on your cold sore. If you’ve got a monster of a cold sore then it may only last through one.


How it works: Lysine is an amino acid your body absorbs when you eat eggs, red meat, cheeses, or fish (among many other sources). By increasing the amount of lysine you eat (either through diet changes or taking lysine pills) or applying a lysine ointment directly onto the cold sore it is believed that you disrupt an important ratio of lysine to arginine (another amino acid) that the virus needs to make copies of itself

Does it work?: It’s not FDA approved for treating cold sores but there’s a lot of buzz and research into it. One trial found that 40% people treated with lysine at Lysine+the first sign of outbreak were rid of their cold sore by day 3.  Pretty awesome if you ask us.

How to use it: There are creams like Lysine+™ that contain lysine as one of the main ingredients that you apply in the same way you apply Abreva at the first sign of a cold sore. There are also pill forms of lysine that you can find in the vitamin section of some pharmacies.  Most sources recommend 1000mg (1 gram) three times a day at the first sign of a cold sore. Some people have found that if they start the lysine pills early enough, they can actually prevent the blister from fully forming (sorry Herpie).

Cost: A tube of Lysine+™ usually costs about $8 for a 0.25 oz tube that will last 2-3 sores. Lysine tabs can range in price depending on the brand (usually around $10) but definitely go for a well-known brand that uses high-quality sources of lysine.

Peppermint Oil (yes, peppermint oil)

How it works: Peppermint oil is thought to have direct viricidal (i.e. virus killing) abilities. How does it do this?  We’re not sure just yet…but if the cold sore goes away, does it matter?

Does it Peppermint Oilwork?: Surprisingly, the answer may be “yes.”  Not enough studies have been done on the subject but it seems like peppermint oil is capable of killing the virus particles that are outside of your cells.  Studies have yet to be conducted on humans or on the exact way to use peppermint oil (dosing, delivery mechanism, etc.) so it’s a little iffy right now.  At the moment its just test tube medicine.  Feeling adventurous?  Might be worth a shot.   People who use it have reported seeing their cold sore disappear faster.

How to use it:  There are no tried and true rules for how to use these oils at the moment but here are some guidelines:

  • Use good quality peppermint oil

  • Dip a cotton swab in water and then into the peppermint oil (this is to help dilute the oil a little because 100% peppermint oil can be very irritating to your skin)

  • Apply on to the cold sore

  • Do this a couple of times a day

  • DO NOT drink the oil.  It won’t help, we promise.

Note: A lot of other natural products like tea tree oil, eucalyptus oil, and lemon balm are also being investigated as possible treatments for cold sores. If any of them interest you, use them similarly to peppermint oil.

Cost: Greatly varies but like with any natural remedy make sure its good quality and from a source you trust. On average though its pretty inexpensive.

You may have noticed that all these products ask you to start using them at the first sign of a cold sore.  This means that you have to be in tune with your body and recognize how your cold sores develop.  Look for warning signs of your next outbreak.  It’s also a good idea to keep track of the things that triggers your cold sore.  If you get a visitor on your lips every time finals come around or workload gets heavy, then start using one of these products preemptively around the start of finals.

Other products:

The products below are frequently advertised as treatments for cold sores but they don’t contain any ingredients that make them particularly active against the herpes virus.  They’re great for keeping your lips healthy and conditioned (nothing some chapstick with SPF wouldn’t do).  They can also help reduce the pain, itching, and redness caused by the cold sore because a many of them have pain-relieving ingredients.  Unfortunately, there is nothing in them that will get rid of the herpes virus and make the outbreak go away faster.

  • ZilactinCarmex

  • Anbesol

  • Blistex Medicated

  • Carmex

  • Orajel

  • Neosporin-LT

  • Campho-Phenique

Again, this is a brief review of products that are available.  The world of cold sole- combating “medications” is filled with a ridiculous number of products but the cure has yet to be uncovered.  The Internet is full of people’s home remedies (from toothpaste to bleach) and products popping up claiming to be FDA approved.  Use common sense and a healthy dose of detective skills when considering any product (we don’t recommend using bleach on your mouth.  It seems like the kind of horrible idea that will land you a Darwin Award).  Find out what the product’s active ingredients are and see if those are chemicals you’d want in or on your body.  Activities that undoubtedly help reduce cold sores are staying healthy and dealing with stress in a healthy way.  Also, do your friends and family a favor and try not to introduce them to Herpie.  If you know you have a cold sore developing, don’t share anything that touches your mouth with them.  Until something better comes along, you and Herpie are just going to have to learn to work together…and do your part to shorten his stay!

Picture 4


Abreva New Drug Application. 20-941. FDA Archives. Oct.29.1999

Elish D, Singh F, Weinberg JM. Therapeutic options for herpes labialis: experimental and natural therapies. Cutis. 2005 Jul;76(1):38-40.

Schuhmacher A, Reichling J, Schnitzler P. Virucidal effect of peppermint oil on the enveloped viruses herpes simplex virus type 1 and type 2 in vitro. Phytomedicine. 2003;10(6-7):504-10.

Singh BB, Udani J, Vinjamury SP, Der-Martirosian C, Gandhi S, Khorsan R, Nanjegowda D, Singh V. Safety and effectiveness of an L-lysine, zinc, and herbal-based product on the treatment of facial and circumoral herpes. Altern Med Rev. 2005 Jun;10(2):123-7.


02 2010

Low Calorie Sweeteners: Have Your Cake & Eat it Too

by Leah Frankel,  MS RD |

Table Sugar

Every January approximately half of all Americans resolve to eat better and lose weight. With increased portion sizes and the evolution of coffee drinks that have more calories than a burger and fries, more and more people are reducing their sugar consumption by choosing low calorie or calorie free sugar substitutes. There are a number of artificial and natural sweeteners on the market, including recently approved Stevia, but which one is really the best choice? We’ll explore the difference between artificial and natural sweeteners, as well as learn about the newest low calorie sweetener, Stevia.

What is the difference between Artificial Sweeteners & Natural Sweeteners?

Artificial sweeteners are chemicals or chemically altered natural compounds that provide sweetness like sugar but with fewer calories. Natural sweeteners taste like sugar but occur naturally as opposed to being synthetically manufactured like artificial sweeteners. Individuals with diabetes have been using artificial sweeteners for years; these “fake sugars” taste like sugar but the body does not utilize them like regular sugar and therefore they don’t raise your blood sugar levels.

Artificial Sweeteners PacketsIn addition to use by diabetics, artificial sweeteners are commonly used to aid in weight loss since they’re low in calories or calorie free. While artificial sweeteners may contain little or no calories, the foods that contain these products may be high in calories, fat or carbohydrates. Let’s look at a few examples showing how artificial sweeteners may aid in weight loss or inhibit it. A regular 12 oz can of coke contains 140-150 calories but a diet coke is calorie free therefore, if we want to cut down our calorie count, the diet coke containing artificial sweeteners would be a better choice. Now another scenario: one serving of Oreos (34g) contains 160 calories. An equivalent serving of CarbWell Oreos, the sugar free version, contains 113 calories.  Murray’s Sugar Free Chocolate Sandwich Cookies contain 131 calories for the same serving. When we look at sugar free cookies vs. regular cookies the ideal choice isn’t as black and white.

Common Artificial Sweeteners

There are a variety of different artificial sweeteners available, each with different chemical properties that allow some of the products to withstand heat, while others cannot. For each sweetener we’ve included the ADI (Acceptable Daily Intake), which is the maximum quantity that is safe to be consumed per day, based on body weight in kilograms (kg) (Note: weight in lbs/2.2 = weight in kg, for example a weight of 150 lbs/2.2 = 66 kg).  As a side note, imagine the lab in which they were testing the “maximum amount of artificial sweetener that can be consumed.”  We’d love to find out what happened there.  Maybe even just see a picture of the whole operation.

Aspartame: Common products containing aspartame include Nutrasweet and Equal.  Aspartame is 200 times sweeter than sugar!  It is safe to consume 50 mg/kg a day which is equivalent to 18-19 cans of diet cola per day (Aspartamebased on body weight of 150 lbs).  We do not recommend trying this.  If you do, however, please let us know what happens with can #20 so we can utilize your discovery for the betterment of mankind.  Aspartame does not withstand heat and therefore cannot be used for cooking. Aspartame is not safe for people with Phenylketonuria (PKU), and an appropriate warning is required on all products containing Asprartame. Aspartame can be found in a number of products including soft drinks, sugar free cookies, chewing gum and yogurt.

Saccharin: Common products containing saccharin include Sweet ‘N Low and SugarTwin.  This sugar-alternative is 200-700 times sweeter than sugar. It is safe to consume 5 mg/kg per day which is equivalent to 9-12 packets of sweetener per day (based on body weight of 150 lbs).  Saccharin is able to withstand heat and is thus can be used for cooking.  Saccharin is most commonly used in diet sodas.

Acesulfame K: This sugar-alternative is 200 times sweeter than sugar and is found in Sunette and Sweet One. It is safe to consume 15 mg/kg a day which is equivalent to 30-32 cans of diet soda per day (based on body weight of 150 lbs). Acesulfame K is able to withstand heat and cooking. Acesulfame K is commonly found in baked goods and diet sodas.

Sucralose: Common products include Splenda and it is 600 times sweeter than sugar. It is safe to consume 5 mg/kg a day which is equivalent to 6 cans of diet cola per day (based on body weight of 150 lbs). Splenda is able to withstand heat and cooking. Sucralose is commonly found in diet sodas, protein bars and sugar free baked goods.

Common Natural Sweeteners

Stevia: The most recent natural sweetener on the market in the US is Stevia. While Stevia has been used internationally for hundreds of years, the FDA only put Stevia on the GRAS (Generally Recognized as Safe) list in late 2008, allowing its use as a sweetener. Stevia Rebaudiana Extract Stevia is an herb that is grown around the world, particularly in China and South America, that, when purified, is 200-300 times as sweet as sugar. Stevia is virtually calorie free and does not raise blood sugar levels, so it can be beneficial for diabetics or people looking to lose weight. While Stevia has been recognized as safe, people taking anti-hypertensive or diabetic medications should be cautious due to possible interactions with their medications (i.e. talk with your doc before jumping on the Stevia train if you’re on these meds). Some people may experience mild side effects including nausea or a feeling of fullness after eating.  A component of the Stevia leaf known as Rebaudioside A (Reb A) is used to make the sweetener. There are several brands of sweetener that use Stevia (these brands vary the components used in their sweetener but all contain Stevia):

  • SweetLeaf Sweetener contains only Stevia and is a zero calorie natural sweetener.

  • PureVia uses Reb A in addition to erythritol (a sugar alcohol), cellulose powder and natural flavor.  The product is 97% Reb A. PureVia can be found in 0 Calorie Sobe Lifewater as well as other Pepsi Products.

  • Truvia contains rebiana (a form of stevia), erythritol (a sugar alcohol) and natural flavors. It is safe and possible to cook with Truvia. Truvia can be found in products including VitaminWater 10, Odwalla, and Sprite Green.

Sugar alcohol: Examples of sugar alcohols include sorbitol or mannitol. Sugar alcohols contain 2 calories/gram vs. 4 calories/gram found in sugar. Sugar alcohols are carbohydrates thatSugarfree Candy resemble sugar and alcohol and therefore are considered “sugar free”. These substitutes are not completely absorbed and therefore can cause gas and diarrhea; any product that contains sugar alcohol will contain a warning label that states that excess consumption may have a laxative effect (i.e “diarrhea” which is scientifically classified as “not fun”).  The American Dietetic Association advises that consuming greater than 50 g/day of sorbitol or 20 g/day of mannitol may cause diarrhea. Sugar alcohols are commonly found in sugar free hard candies, sugar free baked goods and soft drinks.  In addition, sugar alcohols are found naturally in fruits and vegetables.

Honey: Honey contains disease-protecting antioxidants that may help reduce the risk of cardiovascular disease and cancer. Honey is sweeter than sugar and can cause blood sugar spikes.  As such, it should be used sparingly by diabetics.

Agave Nectar LabelAgave nectar: Agave nectar comes from the same Mexican plant that is used to make tequila. While it contains higher calories per teaspoon than sugar, it is a sweeter alternative and therefore less is needed to obtain the same level of sweetness. Agave is favored by vegans who are opposed to the use of honey (no bees are harmed in the making of agave nectar…party on vegans!).

So what should we choose as a sweetener?

Any of the artificial or natural sweeteners we’ve discussed, as well as sugar, are fine in moderation. According to the National Cancer Institute, there is no risk for developing cancer if you consume artificial sweeteners in moderation. If you’re a diabetic or trying to lose weight it may be beneficial to choose a low calorie sweetener instead of sugar to control blood sugar and caloric intake. At the same time, this does not means that you should only consume foods with low calorie sweeteners; a diet consisting of diet coke and sugar free cookies may be lower in calories but it is also missing some key nutrients (and sounds pretty horrible to have to eat every day). Remember that the most natural form of sugar can be found in nature’s candy: fresh fruit!

Fresh Fruit


Artificial Sweeteners and Cancer. 2009. Available at: Accessed Feb 10, 2010.

Mayo Clinic Staff. Artificial sweeteners: A safe alternative to sugar? Find out the benefits and portenital pitfalls of using artificial sweeteners. 2008. Available at: Accessed Feb 10, 2010.

PureVia: Available at: Accessed Feb 11, 2010.

SweetLeaf Sweetener. Available at: Accessed Feb 11, 2010.

Truvia. Available at: Accessed Feb 11, 2010.


02 2010

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