Alpine Spine & Orthopedics

Nutrition:

Optimize your performance, healing, and recovery with nutrition

Nutrition is a fascinating topic where knowledge is continually advancing and which closely intertwines with biochemistry, cell biology, and exercise science. With a generally healthy diet, the body can generally adapt to a variety of nutritional sources with overlapping and compensatory metabolic pathways. However, for athletes who have prolonged training loads, immense metabolic demands, stressful training schedules, and strict diets, we want to biohack nutrition to get the most potent desired effects on performance while not diminishing any essential micronutrients that are essential for long-term health and performance. Similarly, for those seeking to lose weight or optimize their metabolic health, we can also do many lab tests of vitamins, minerals, electrolytes, hormones, and other factors that can impact your performance.

For those seeking maximal understanding of their health status, we can order an intricate panel of bloodwork to test a wide range of micronutrients, vitamins, hormones, macronutrients, lipids, sugars, antioxidants, organ functions, allergens, and metabolic screenings that help you understand how to best tailor your health goals. We discuss the most relevant nutrition to your particular sport, training regimen, weight loss program, or medical condition and provide several nutritional recovery options. Optimizing nutrition for each individual can take time, but we provide good principles, personalized modifications, and specific data that can easily be adapated to your training loads and cycles below, and we have a youtube video discussing the best nutrition for injury prevention and recovery as well as for optimal recovery, healing, function, and performance.

Although athletes may not realize it, top athletic performance often depends as much on tendons and ligaments as it does on muscle, especially in sports like running and climbing. Vitamins and minerals act as essential "co-factors" that help tissues continually rebuild themselves and help cells and enzymes do their vital jobs. Thus is it essential to optimize the nutritional health for your particular training and activity. Most vitamins and minerals do not need excessive supplementation, but many athletes have been surprised to find that in the process of their intense training and high metabolic demands they have become deficient in one or more nutrients despite reporting a generally healthy diet. The knowledge below helps athletes protect themsevles and optimize their performance naturally. The obligatory disclaimer: this is for informational purposes only, not entirely comprehensive, and your own situation may be unique and should therefore be implemented in consultation with a professional who is knowledgeable about this information and can link it in with the rest of your medical history. Some of the supplements described below are discussed because we do NOT recommend them, and we do not endorse any particular brand of supplements, but we do offer pharmaceutical grade quality of many of these vitamins and nutrients as IV drips and injections in the clinic for those who need them:

DR. MCMURTREY's NUTRITION GUIDE FOR INJURY RECOVERY, TISSUE REPAIR, & OPTIMAL PERFORMANCE:
 
• General Diet - Despite the complexity of nutrition and so many intersecting biochemical pathways happening in the cell, I try to keep the concept of diets simple and therefore in many cases advocate for a plant-based diet that is high in antioxidants, anti-inflammatory agents, HDAC-inhibitors, and many other natural nutrients (i.e., predominantly vegetarian). This also includes omega-3 fatty acids, leafy greens (iron, quercetin, rutin, numerous vitamins and minerals), blueberries (anthocyanin and pterostilbene), carrots (luteolin, carotenoids, numerous vitamins and nutrients), broccoli (quercetin, luteolin, calcium, phosphorous, zinc, etc.), grapes (resveratrol, quercetin), plus lots of water, all of which can then be further tailored to your particular tastes and needs, described further below. These foods have also been shown to provide numerous cytoprotective and anti-aging effects on cells as well as cognitive benefits. The 2009 Nobel Prize winning discovery of telomeres and telomerases was first made in the ancient long-lived Bristlecone Pines, then found to also be at work to a lesser degree in human cells. The discovery of the mTOR enzyme also uncovered a fascinating mechanism of metabolic controls in the cell, where mTOR acts as a major regulator of cell metabolism and is heavily involved in stem cell differentiation, acting as a sort of integrated metabolic switch and fuel sensor of oxygen, amino acids, and energy supply-- when mTOR is inhibited under hypoxic or low-calorie conditions (as happens in endurance exercise), it promotes stem cell mainenance and regenerative capabilities. Dr. McMurtrey published a summary of his own stem cell research work describing the complexity of these signaling pathways in the academic journal Stem Cells & Development. Evidence suggests that the above-listed natural phytochemicals, flavonoids, anti-oxidant-rich, fiber-rich, vegetable-focused diets, along with exercise, can re-map cellular epigenetics, enhance telomere length, and inhibit mTOR to promote stem cell maintenance and the cellular regenerative capabilities of more youthful cells both in laboratory culture and in the human body (1a)(1b).
• Neuropathy, Neuritis, & Myelin Repair Nutrition - the myelin that supports proper nerve signal transmission is made primarily of lipids (70%), including phospholipids (50%), cholesterol (27%), and glycosphingolipids (17%), and the rate-limiting step in myelin synthesis appears to be cholesterol production. About 30% of myelin is protein embedded in the fatty layers. Evidence suggests supplementation with phospholipids can help repair myelination defects (2), so those with neuropathic conditions may want to consider supplementing with various components of myelin. The study referenced above used 55% phosphatidylcholine + 20% phosphatidylethanolamine as 3% of the diet, with most of the fats being lineoleic components (60%) as well as smaller amounts of oleic, linolenic, palmitic, and stearic fats. It may also be useful to add protein and cholesterol such as that found in eggs, as well as omega-3 fatty acids, lecithin (which makes up ~11% of myelin) and alpha-lipoic acid, which we can provide as an IV infusion (3) (4). Eggs have the added benefit that they have small amounts of FGF that promotes tissue repair and mesodermally-directed stem cell differentiation, plus they are composed of a very similar amino acid composition to muscle, meaning that when they repair muscle there is not a lot of extra amino acids left over for conversion into fat. Because L-carnitine helps transports fats into the mitochondria and metabolic byproducts back out, it may also play an important role in remyelination. Palmitoylethanolamide from nuts and egg yolks may also act as an anti-inflammatory agent and analgesic in addition to membrane repair. Several other agents such as α-lipoic acid, benfotiamine, CDP-choline, curcumin, quercetin, vitamin B12, vitamin D, palmitoylethanolamide (PEA), and EGCG (from green tea extract) have also shown some evidence of benefit in nerve repair and neuroprotection. Vitamin B12 in particular can provide significant therapeutic benefit for some peripheral neuropathies and other forms of neural injury, and we are one of the few clinics in the world that can perform image-guided injections of B12, Folate, Glutathione, PRF, Peptides, ALA, D5, Corticosteroids, and other agents directly around injured nerves to optimize myelin repair at the injury site (5) (6) (7) (8) (9) (10) (11). The peptides page, PRF page, and infusion page further discuss more potential re-myelination therapies with good scientific support. For more information on cognition and nootropic agents, please visit our cognition page.
• Cell Membrane Repair Nutrition - Along with the above information on myelin repair, two efficient ways of providing precursors for cell membrane repair are Alpha-GPC (glycerylphosphorylcholine) and CDP-choline (which is split by the intestine then reformed after crossing the blood-brain barrier to provide choline to neurons). CDP-choline also acts as a precursor for lipids mentioned above and may provide numerous beneficial effects including neuroprotection, glutathione production, cell membrane repair, myelination, neural repair, antiinflammation, improved mitochondrial function and metabolism, concussion recovery, stroke recovery, and GH stimulation (12). Alpha-GPC can also act as a precursor for choline in the brain and may confer a potential performance benefit. In one study just a week of Alpha-GPC supplementation prevented exercise-induced reductions in choline levels, increased endurance performance, increased growth hormone secretion, and increased isometric strength (13) (14). When Alpha-GPC is ingested, it is converted to PC which is the most abundant cell membrane lipid.
• Tendon & Ligament Repair Nutrition - the best evidence so far for nutritional support of tendon repair and increased collagen synthesis includes naturally augmenting your own growth hormone release, which includes glycine, collagen, vitamin C, vitamin D, melatonin, the micronutrients described above, and good sleep, all of which are described in much greater detail on our nutrition video. This is best done in conjunction with our other medical interventions of PRF and shockwave therapy as well as new injectable medications and peptides that are being studied for their therapeutic benefits in tendon and ligament repair.
• Cartilage Repair Nutrition - some clinical studies have suggested improvements in osteoarthritic joint pain, lubrication, inflammation, swelling, and oxidative damage with various combinations of Glucosamine + Chondroitin + MethylSulfonylMethane (MSM) + Hyaluronic Acid, and these appear to be most effective when taken together (15) (16) (17) (18) (19) (20) (21) (22) (23). However, while some data suggest these prevent the breakdown of cartilage, the data are not conclusive and one recent study even showed no significant difference compared to placebo (24). Unlike some alternative therapies, oral supplementation does not appear to show evidence of cartilage regeneration, but overall data do not suggest that there is harm in taking these medications. MSM in particular may enhance collagen production and glutathione production. Glucosamine/Chondroitin/MethylSulfonylMethane/Hyaluronic Acid all act to help form glycosaminoglycans ("GAGs"), which help form the ECM ground substance that collagen structures are built on. Specifically, glycosaminoglycans are polysaccharides that are linked to a proteoglycan core, e.g., chondroitin sulfate, heparan sulfate, dermatan sulfate, as well as hyaluronic acid (non-sulfated) or keratan sulfate (not linked to a proteoglycan). This ground substance tends to be upregulated in connective tissue injury, but it is not known if oral supplementation with these substances is actually beneficial to the healing process. Interestingly, however, new injectable therapies are showing great promise in osteoarthritis. Injectable "GAGs" like pentosan sulfate and/or chondroitin sulfate with hyaluronic acid can now be used to help lubricate and restore hyaline cartilage! For example, a 2016 study showed that injection of chondroitin sulfate and hyaluronic acid into osteoarthritic joints resulted in a 77% reduction in pain and 78% improvement in mobility (25), and we can perform these minimally-invasive sterile procedures at the Alpine Spine & Orthopedics clinic, as well as many other novel therapies discussed in greater detail on our osteoarthritis page.
• Glutathione - the body's most important antioxidant, this is composed of three amino acids (including glycine above, plus glutamine and cysteine). Because it requires glucose in its synthesis, it is especially prone to become depleted in long-distance runners, cyclists, and other athletes who routinely deplete glycogen stores under prolonged oxidative stress. It also declines as we age and during illness, and some evidence suggests that its supplementation can significantly benefit Parkinson's disease, autoimmune disease, chronic fatigue syndrome, collagen disorders, neuroinflammation and other inflammatory conditions. Because it is quickly degraded by digestive enzymes when taken orally, it can be given as an IV drip or injection either prophylactically or for recovery after an event.
• B12/B6/Folate - one of the most important functions of these vitamins relates to methylation functions, regulated in part by the MTHFR gene. In fact, folate, choline, betaine (trimethylglycine or TMG), vitamin B12 (methylcobalamin), and other B vitamins serve as methyl donors and co-factors for DNA replication, red blood cell production, neurological functions, immune system functions, and epigenetic modifications. Because B12 and folate are involved in essential methylation reactions for DNA synthesis and cell replication, the most effective form of these vitamins is methyl-cobalamin and methyl-folate. Deficiency of these forms leads to impaired cell replication, which can manifest as a megaloblastic anemia, especially in vegetarian-based athletes, athletes who are deficient in intrinsic factor, or age-related loss of intrinsic factor and limited B12 absorption. Note that B6 (pyridoxine) is one of the few water-soluble vitamins that should not be taken in excessive amounts due to risk of toxicity (neuropathy), and folate supplements should also be taken in controlled amounts and only when B12 levels are normalized. Deficiency in B12 can result in elevated homocysteine that interferes with proper collagen cross-linking, putting athletes at risk of cardiovascular disease and tendinopathies, and thus we recommend B12 shots for those at risk of low B12 (vegetarian, malabsorptive, older, or higher metabolic demand/high cell turnover athletes) (26) (27) (28) (29) (30) (31). Again, it is important to ensure you are getting optimal forms of B12 and folate that are immediately usable by the cell, which include the methylated forms of methylcobalamin, methylfolate, or methyltetrahydrofolate (L-5-MTHF), and in some cases the unmethylated forms such as calcium folinate or folinic acid. We can also do lab testing for MTHFR variants that may cause methylation disorders.
• Vitamin C – necessary for proper collagen synthesis (hydroxylation of proline and lysine, discussed above), immunity, ceramide production, and connective tissue functions, as well as a well-known anti-oxidant at low doses. The body cannot store vitamin C (ascorbic acid), so old world sailors carried citrus fruits to replenish vitamin C on long adventures at sea to prevent scurvy, a disease characterized by poor collagen fibrillogenesis with skin, bone, and muscle pain and fragility. Strangely, at high doses vitamin C can become pro-oxidative, which may actually be used as a feature along with magnesium infusions to promote anti-cancer effects (e.g., against colon and breast cancer) (32).
• Glycine - the main component of collagen in tendon and ligaments (a third of collagen mass), as well as a powerful antioxidant, an important precursor for creatine, and a neurotransmitter that can enhance healthy release of the body's natural growth hormone and induce deeper sleep for better recovery. Evidence suggests it increases collagen synthesis, reduces atherosclerosis, reduces inflammation, reduces blood pressure, and may even extend lifespan (33) (34) (35) (36) (37) (38) (39) (40) (41) (42). It can be taken as an oral supplement, an injection, or naturally in fish, chicken, and gelatin foods. Because it is such an abundant component of tendons and ligaments, it is highly recommended for runners, climbers, and any athletes who depend on connective tissue strength.
• Collagen - similar to glycine, collagen supplementation appears to enhance collagen synthesis in the body (43) (44) (45) Collagen is the most important structural protein in the body, making up about a third of the body's protein content, and primarily produced by various types of fibroblast cells. Type I collagen is the main component of tendon, ligament, bone, and skin. Type II is more prevalent in joint cartilage, while Type III is the second-most abundant in the body and mostly in elastic tissues like vessel walls and bowel but also important in the genesis of type I collagen. Type III has thinner reticular-like fibers and is increased at sites of injury where it appears to regulate differentiation of reparative stem cells... knocking out type III collagen increases the presence of myofibroblast cells that contract wounds more quickly but which leads to hypertrophic scarring and unstable wound repair (46). Type IV collagen forms basement membrane that divides tissue compartments and surrounds muscle fibers, while Type V binds to other forms of collagen as well as dozens of other matrix proteins present in structural tissues (like laminin, fibronectin, fibrillin, elastin, etc.), which appears to be an essential part for proper self-assembly and fibril formation although the exact mechanisms are still being elucidated. It is not known if oral supplementation of any particular type of collagen influences collagen synthesis in healthy or injured tissue. The trimer helixes of protocollagen are only a few atoms thick, and they begin assembly in the endoplasmic reticulum where they are glycosylated and hydroxylated (with vitamin C as a necessary co-factor) which stabilizes hydrogen bonding in the exported triple helix conformation called tropocollagen (47). Tropocollagen is then aligned outside the cell in a periodic pattern of side-by-side fibrils where these fibrils thicken as they band together into larger fibers. The previously hydroxylated residues of lysine are then covalently bound with aldol crosslinks between fibrils for mature collagen strength (an enzymatic process that requires copper, discussed below). Additionally, the reactive aldol groups on hydroxylysine also react non-enzymatically with sugar to create covalent glycosylated cross-links ("advanced glycation end-products") between fibrils that can add further strength, but interestingly under states of cell death and inflammation the fibrils can become over-glycated by release of sugar and other contents from dying cells, which appears to impair the ability of newly-synthesized collagen fibers to bind to older fibers and thus impairs proper tendon regeneration, and this may explain the efficacy of treatments like shockwave therapy, PRF repair, and new injectable ECM investigational medication, which is an area of active ongoing research at AAMI (48) (49) (50) (51). Bone broth is an excellent natural source of collagen, electrolytes, and many regenerative nutrients without having to take powder/pill supplements.
• Melatonin - when taken at night (minimum effective dose is ~5mg in adults, recommended up to 10mg, and ideally taken along with 1g of glycine), can also enhance your body's own natural Growth Hormone release, which promotes tissue repair of tendon, ligament, and many other tissues and organ functions (see the peptides page for more info) (52) (53) (54).
• Omega-3 Fatty Acids (EPA, DHA, & ALA) - in addition to being protective against cardiovascular disease, these are essential in neurodevelopment and in recovery for rebuilding cell membranes after cellular damage. They have also been shown to have anti-inflammatory properties and may be protective against dementia, arthritis, neuropathy, and cancer (55) (56) (57) (58) (59) (60) (61). Alpha-lipoic acid can help repair neuropathies and remyelinate nerves (see the neuropathy repair section). The latest evidence suggests that EPA provides the greatest benefits and most protective effects in older adults while DHA is more important in younger development.
• Vitamin D - restores collagen expression in tenocytes (tendon cells) after damage with corticosteroids (62). Vitamin D3 is necessary for healthy bones as it regulates the body’s ability to absorb calcium, thus it has good effects on muscle, bone, and other tissues. Good evidence suggests that a simple dietary supplement of 500-1000IU of Vit D + Calcium + up to 5g of collagen supplement + weight-bearing exercise can all naturally enhance bone density. Take this during the day (for example, along with Omega-3s), not at night since it can impair your ability to spike GH from the pituitary at night while you sleep.
• Natural Anti-Inflammatory Agents - when cells are damaged they can initiate many different types of inflammatory signaling pathways like release of arachidonic acid from the cell membrane. Arachidonic acid is converted to prostaglandins (by the cyclooxygenase enzyme), which process can be inhibited by traditional NSAIDs. However, NSAIDs do not stop the other inflammatory pathway of leukotriene synthesis (by the lipooxygenase enzyme), but this process can be inhibited by natural substances such as turmeric (containing curcumin), omega-3 fatty acids, ginger, boswellia, devil's claw, bromelain, papain, rutin, lion's mane mushroom, various flavonoids, etc., with less risk of GI erosions (although these may still have some effects on coagulability) (63) (64) (65) (66) (67). Additional antioxidans and tissue repair agents like glutathione and trimethyl-glycine (TMG) are further discussed below. Further research is needed to decipher in what specific injuries or conditions these agents are most applicable and most effective, with the consideration that many other signaling cascades and overlapping processes can also be involved in degenerative pain mechanisms. It is always important to avoid pro-inflammatory foods like trans-fats (hydrogenated fats), fried foods (especially cheap oils like soybean oil and seed oils), sugar, simple carbs (flour, starch, etc), dyes, processed foods, and alcohol. It is also possible to have inflammatory immune reactions to gluten, milk, nuts, seafood, or other foods, and we can test for these allergies in labs and blood work.
• Summary of Some Tissue-Protective Anti-Oxidant Agents:
  Glutathione
  Glycine
  Betaine (Trimethyl-Glycine)
  Magnesium
  Omega-3 fatty acids
  Resveratrol
  Luteolin
  Quercetin
  Rutin
  Vitamin C
  Vitamin D
  Vitamin E
  Vitamins B6/B12/Folate
  Co-Q10
  Turmeric/Curcumin
  N-acetylcysteine (in certain cases, see below)
  Polyphenols (EGCG, tea, cocoa, pomegranate, coffee, chocolate, etc)
  Note: Arginine and Homocysteine are pro-oxidative and can compete for cellular uptake with other amino acids.
• Nicotinamide Riboside/NR/NAD+/Nicotinamide/NMN/Niacin - these are all various forms of Vitamin B3. Niacin is the most well-known form, and has been used to increase good cholesterol (HDL), but also tends to cause notable flushing and can cause liver damage if taken in excess. Nicotinamide may help acne but unfortunately appears to inhibit sirtuin enzyme functions, which is the opposite of what we want for anti-aging protection. Nicotinamide Riboside is a precursor for NAD+, both of which have been shown to activate sirtuin activity, modulate PARPs, repair DNA damage, and suppress inflammation. Although present in milk in trace amounts, NR and NAD+ are difficult to obtain in the diet in significant amounts, and their levels in our bodies decline significantly as we age. These vitamins play essential roles in energy metabolism and appear to act at least in part by mimicking states of calorie-restriction and hypoxia, which correlates with other research that calorie-restriction can help extend lifespan in animals and that hypoxic states help renew stem cell activity. See the aging page for more information and references on these substances.
• HDAC-inhibitors - substances that help modify the epigenetic landscape in the cell (68) (69) (70), which may influence many processes from aging to chronic diseases. They include things like luteolin, quercetin, caffeic acid, and butyrate, which also tend to be good antioxidants and can act as senolytic agents that suppress specific causes of age-related inflammation and selectively clear out damaged senescent cells (71) (72) (73) (74) (75) (76). Luteolin (in nuts, celery, broccoli, carrots, etc.) may help increase factors like NGF, GDNF, BDNF, and may also act as an anti-inflammatory, antioxidant, antimicrobial, and anti-cancer agent, although further research is needed (77) (78). It appears that betaine, glutathione, levocarnitine, and quercetin (in green leafy vegetables, beets, onions, broccoli, etc., but also available as supplements) may impart a slight endurance and recovery advantage, and in research experiments these have been shown to enhance power and prevent age-related decreases in hanging endurance, grip strength, and speed: (79) (80) (81) (82) (83) (84).
• Anaerobic Enhancing Agents - many different types of agents have been shown to enhance brief bursts of power under anaerobic (non-oxidative) metabolic conditions. Some examples include caffeine, creatine, beta-alanine, L-citrulline, L-arginine, L-tyrosine, taurine, hordenine, piperine, capsaicin, huperzia, and many others (85). Because these agents act through a variety of mechanisms, there may be synergistic effects by using more than one at a time, but there may also be detrimental effects with some combinations, and side-effects of each should be taken into consideration.
• Zinc - these are involved in essential functions involving tendon healing, collagen production, hormone production, immunity, DNA replication, and more (86) (87) (88). As with most vitamins and minerals, if you are eating a healthy varied diet, it is not typically essential to take a supplement every day or in large doses, but adding a zinc+copper supplement to ensure levels are adequate (~25mg/2mg respectively) can be beneficial in most cases. However, zinc should not be taken in overabundance-- if you routinely take large doses, it prevents the absorption of copper, which is also needed in tiny but mandatory amounts for proper neural function, retinal function, and collagen cross-linking. Excessive zinc consumption has led to copper deficiency, which results in myelopathic degeneration and megaloblastic anemia that mimics a B12-deficiency (89), and so it is likely best to actually use a zinc+copper supplement.
• Calcium – necessary not just for bones but also for many other tissues, calcium ions activate muscle contraction when released from SR as well as numerous other essential cell signaling pathways. Dietary foods high in calcium are the best source as they have the best absorption, lower risk of kidney stones, and do not cause excessive calcium buildup. Bone is composed primarily of calcium, phosphorus, and type I collagen, and calcium has been shown to stiffen collagen, which is good for type I collagen in bones and ligaments, but not good for type II articular collagen since the supple cartilage can become stiffened and susceptible to earlier osteoarthritis with calcification (90). Furthermore, culture of fibroblasts with high calcium levels decreased the total synthesis of collagen and glycosaminoglycans, suggesting calcium supplementation would not benefit collagen strength in connective tissues (91). Thus for optimizing bone density, good evidence suggests that simple balanced dietary supplementation of 1000IU of Vit D + Calcium-rich foods + ≤5g of collagen + weight-bearing exercise can all enhance bone density in a safe yet meaningful way. Additional medical therapies are also available for those at high risk of osteopenia or bone resorption.
• Magnesium - similar to calcium, this small atom supports hundreds of different enzymatic processes. It is needed for proper absorption and transport of calcium and potassium into cells, it helps activate Vitamin D, and it protects against mitochondrial dysfunction and oxidative stress (92). It tends to be depleted in dehydrated athletes or long-distance runners along with potassium and chloride (depending on fluid intake and many other factors) (93) (94).
• Manganese - essential for collagen synthesis, skin repair, growth, development, and mainenance of human health, this is a necessary co-factor for numerous enzymes and also capable of acting as an antioxidant. There is a risk of neurological damage from excessive manganese, but a simple healthy diet of vegetables, grains, beans, or nuts, etc. should provide all the manganese needed for the body. Manganese and copper can aid antioxidant pathways and superoxide-dismutase (SOD) activity, and their deficiency tends to promote inflammatory pathways like IL-1β, but these trace elements should also not be taken in excess since high levels can actually be pro-oxidant (although taking these with zinc can help balance out oxidative activity) (95) (96) (97).
• Potassium - under most conditions, our kidneys manage potassium concentrations brillliantly, but at certain extremes this process can break down. For example, under states of dehydration or extreme fluid and electrolyte loss, the body attempts to retain as much intravascular fluid as possible by resorbing sodium from the kidneys to maintain blood pressure and flow, but in this process it exchanges the sodium for potassium, meaning sodium is taken back up into the blood while potassium is lost in the urine. This also tends to be associated with losses of bicarbonate (hypokalemic alkalosis). Supplementation with potassium can be essential during such extreme conditions of endurance activity. However, athletes should also be aware that with loss of fluids and a contracted intravascular volume after repeated muscle contractions, it is also quite possible that potassium concentrations are high in the blood, and thus fluid and electrolyte replacement is a complex yet essential topic to understand for athletes. We therefore provide IV infusions and recovery therapies.
• N-Acetyl Cysteine (NAC) - an antioxidant that scavenges free radicals and that also helps sustain the production of another antioxidant, glutathione, discussed above. Because oxidative stress has been shown to be an important mediator of osteoarthritis (OA) (98) (99), it was thought that NAC may help slow or prevent this process based on animal data, but unfortunately in human trials this did not work and may even be detrimental (100) (101), possibly due to NAC's ability to reduce disulphide bonds in procollagen and proteoglycans, or a variety of other mechanisms.

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*Disclaimer: The information presented here is for informational use and cites the ongoing cutting-edge research and medical advancements on these relevant topics. There are many treatments, interventions, and protocols routinely practiced in medicine and surgery which the FDA has not studied nor formally approved yet which have demonstrated overwhelming evidence of efficacy and clinical benefit. The FDA does not regulate the practice of medicine but rather regulates medical marketing of devices and drugs. The FDA does not conduct clinical trials or attempt to discover new treatments, but rather requires companies or other entities to fund marketing approvals. Breakthrough technologies typically require years to decades of research work to optimize the technology and collect enough data to prove efficacy and superiority, which in some cases can optionally be submitted to the FDA if there is sufficient financial backing to market a specific product or drug. Thus the FDA has not yet studied, evaluated, or formally approved many regenerative therapies currently practiced by many of the top physicians and surgeons in the United States and around the world. Some therapies, products, or interventions may still be considered investigational or "off-label" even with substantial evidence of efficacy, and many different applications of regenerative therapies continue to be researched by our institute and other top institutions around the world. We seek to always provide the highest-quality evidence-based care to our patients, which may include FDA-approved therapies as well as additional investigational or alternative therapies. We always discuss potential risks and benefits of all these options. The rapid evolution and advancement of medicine demands that physicians continually update their knowledge and practice techniques to adapt to future improvements and advancing technologies. These statements have not been evaluated by the FDA, and the treatments and products presented here are for informational purposes and not intended or guaranteed to diagnose, treat, cure, or prevent any specific disease or condition. All injuries and conditions should be formally evaluated by a knowledgeable medical professional whereby standard treatments and/or additional therapeutic interventions may be considered with the diagnosis and treatment plan.