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Getting manhandled.

I first encountered ART in 2001 through Frank Shamrock, five-time middleweight Ultimate Fighting (UFC) champion.

Frank had his first ART treatment in July 2001 following an acute lower back injury during training. He was unable to walk and didn't expect much:

I had seen more than 30 chiropractors throughout the world over a 16-year period for lower back pain and numbness in my leg. With the training injury that prompted my visit, I couldn't raise my head above waist-level, and I was sleeping on the living room floor in the fetal position. I had always been told one of two things by orthopedists and various MDs: I would need to have my vertebrae fused, or simply tolerate the pain of an injury that was irreversible. Based on past experience, I was certain that I would need to cancel the K-1 kickboxing fight I had scheduled for one month later.

In four sessions of approximately 10 minutes each, the doctors at the Janzen & Janzen Sports Health Clinic in San Jose, California, eliminated the c.u.mulative scar tissue and adhesions that had created the pain in Frank's lower back. He was carried out of the gym on his trainer's shoulders on Thursday and was training at 100% the following Tuesday.

Three weeks later, Frank won his K-1 fight by first-round KO. Frank then recommended ART to B. J. Penn, Brazilian Jiu-Jitsu World Champion, who used ART to restore full range of motion to his left shoulder (preventing surgery), right shoulder, and hamstring, among other areas. Two weeks prior to the November 2, 2001, UFC championship, B. J. Penn's lower back pain was treated successfully in two 15-minute sessions. B.J. proceeded to knock out a heavily favored Caol Uno in just 11 seconds of the first round.

Experimenting with ART Flash-forward to an overcast and dreary afternoon in New York City, December 2009.

Freezing rain was falling in sheets outside of the Peak Performance gym where 20 or so strength trainers, coaches, and I had been taking an all-day seminar on PIMST (Poliquin Instant Muscle Strengthening Technique), developed by professional and Olympic trainer Charles Poliquin. For each diagnostic and training exercise, we paired off with partners and tested range of motion. For the first exercise, we'd looked at both external and internal shoulder rotation (for the latter, imagine the motion of arm wrestling or pitching a baseball). My external rotation was excellent, but my internal rotation was so close to immobile that my partner thought I was joking: "Wow. You're kidding, right?"

Unfortunately, I wasn't kidding. I couldn't remember the last time I'd been able to touch most of my back. Reminded of this handicap and a bit demoralized, I approached Charles during a break to ask him for recommendations. He paused for a second and looked at me: "Would you like me to fix it?"

I wasn't sure how to answer.

"That would be incredible" was all I could get out. Charles led me to a ma.s.sage table on one side of the gym and asked me to lie down. He gathered all of the students for a demonstration of removing adhesions and restrictions.

Quite the demonstration it was.

Though I was the weakest male in the entire group, the big boys and Westside-style powerlifters had more respect for me 20 minutes later. It was clearly the most painful thing they had seen in a long time. Poliquin, who'd used ART on his athletes under Mike Leahy for four years, had to use two hands: "You know it's bad when I have to use two hands. I never never have to use two hands." have to use two hands."

He had two 200-plus-pound a.s.sistants guiding my arms through movements as he applied enough pressure to put his fingers a good inch in between muscles that had either fused to bone or fused to adjacent antagonistic muscles. I felt like a Thanksgiving turkey.

The before-and-after photos below tell a more complete story.

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Before treatment-the range of motion of a pinata. Notice Charles laughing.

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During the treatment.

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After treatment.

Charles estimated he'd need three or four more sessions to fix the restriction in both shoulders completely. It wouldn't be the first time he'd helped resurrect shoulders: "A few years ago, my good friend and IFBB professional bodybuilder Milos Sarcev called me out of the blue. He mentioned that he was scheduled to have arthroscopic surgery the following week for both of his shoulders. He was understandably upset. For one thing, the surgery would cost him about $18,000. Additionally, he'd have to undergo an extensive rehab program, and this would keep him from competing and earning an income for a long time. I told him to get his a.s.s over to my office right away and see [Dr. Mike Leahy] before letting a surgeon anywhere near his shoulders.

"When Milos came to the office, he hadn't trained in over four months because of the excruciating pain. Even lowering an unloaded Olympic bar (45 pounds) caused him to recoil in pain. However, after working on him [on adhesions around his subscapularis muscle] for just 45 minutes, Dr. Leahy told Milos to go to the gym and give his shoulders a trial run. Somewhat reluctantly, Milos allowed me to take him to the local World Gym. In total disbelief, he bench-pressed 315 pounds for two reps. Five days later, he did 6 reps with 315 pounds without feeling any pain!"

ART sessions are typically 515 minutes in length and cost $45100 each. Most client injuries are treated in one to six sessions. Soft-tissue injuries eligible for ART treatment include rotator cuff impingement, tendinitis, low-back strain, ankle and wrist sprain, shin splints, hip flexor impingement, and carpal tunnel syndrome.

But ART isn't perfect.

As Charles noted: "ART is 100% effective in 70% of patients."

Fixing chronic pain often requires a combination of therapies. Sometimes that involves needles, which brings us to the next stage: medication.

5. PROLOTHERAPY. AREAS FIXED: LEFT KNEE, RIGHT WRIST.

In prolotherapy (so named for the "proliferation" of collagen fibers it's supposed to produce), a mixture of irritants are injected into tendons, ligaments, and inside joints themselves. The objective is to create a mild inflammatory response that stimulates tissue repair.

The simplest of prolotherapy c.o.c.ktails, and the one with the longest track record, was developed by the founder of the technique, George Hackett MD. His mixture is, in effect, "sugar water": dextrose mixed with a local anesthetic (lidocaine) and saline (salt.w.a.ter).

Dr. C. Everett Koop, the 13th surgeon general of the United States, opened the doors for wider research on prolotherapy when he publicly endorsed it:

Prolotherapy, unless you have tried it and proven its worth, seems to be too easy a solution to a series of complicated problems that afflict the human body and have been notoriously difficult to treat by any other method....When I was 40 years old, I was diagnosed in two separate neurological clinics as having intractable (incurable) pain. My comment was that I was too young to have intractable pain. It was by chance that I learned that Gustav A. Hemwall, M.D., a pract.i.tioner in the suburbs of Chicago, was an expert in prolotherapy.... To make a long story short, my intractable pain was not intractable and I was remarkably improved to the point where my pain ceased to be a problem.The nice thing about prolotherapy, if properly done, is that it cannot do any harm. How could placing a little sugar-water at the junction of a ligament with a bone be harmful to a patient?

In 2005, doctors at the Mayo Clinic began testing prolotherapy and identified the most responsive injury sites as the knees, elbows, ankles, and the sacroiliac joint in the low back. They concluded in their newsletter that "unlike corticosteroid injections-which may provide temporary relief-prolotherapy involves improving the injected tissue by stimulating tissue growth."

The prolo c.o.c.ktail I used at the clinic mentioned at the opening of this chapter had a few additional ingredients:

DextroseMarcaine (anesthetic)B-12ProlineLysineGlucosamine sulfate My first session entailed 12 prolo injections. It wasn't all fun and games. For 45 minutes after the first session, I had vertigo and a cold, numb right hand.

On the positive side, decade-old pain in my right wrist (from impact in gymnastics) and my left knee (wrestling) both disappeared approximately 21 days after the last session.

The dangers of the ingredients are minimal, particularly when a simple dextrose-based version is used, but there is always the risk, albeit small, of infection. If a needle pa.s.ses through the skin, it can carry bacteria from the skin into the target site. This is most serious when the infection occurs inside a joint and turns it septic, a process that can cause the joint cartilage to deteriorate in as little as 72 hours.

A survey in France reported an overall risk of sepsis of 13 per 1 million injections, with a much lower incidence if prepackaged syringes are used.

That said, after one staph infection, I was eager to explore less invasive injections, which led to the next therapy: biopuncture.

6. BIOPUNCTURE. AREAS FIXED: INFRASPINATUS, ACHILLES TENDON.

"Can you hear that?"

I could, and it was disgusting. Dr. Lee Wolfer was in the process of giving me between 40 and 60 injections1 with small needles commonly used for tuberculosis tests. Each injection was no more than half an inch under the skin, but the noise emanating from my infraspinatus, one of the rotator cuff muscles in the shoulders, sounded like someone walking on hard snow: audible crunching. with small needles commonly used for tuberculosis tests. Each injection was no more than half an inch under the skin, but the noise emanating from my infraspinatus, one of the rotator cuff muscles in the shoulders, sounded like someone walking on hard snow: audible crunching.

"That's calcium deposited where it shouldn't be."

Lee, one of the foremost spine and back specialists in the United States, then got back to work. The injections weren't close to done. I'd given her a laundry list-neck, upper back, shoulders, ankles-and we had a lot of ground to cover.

Lee is now a die-hard fascist. "Fascist," that is, in the sense of someone who treats the long-neglected fascia as more than just anatomical glue. The results have, so far, been impressive: "I'm finally happy as a doctor. I'm helping my patients' bodies to heal themselves."

The "fascia" comprise a three-dimensional web of fibrous connective tissue that maintains the structure of the body. Think of fascia as the ropes that hold the tent in its shape. Ropes that help to bind muscles together and keep internal organs suspended, among other things. Ever heard runners complain of plantar fasciitis? It's a fascial problem, and a painful one. The plantar fascia of the foot is a thick band of connective tissue that extends from the heel to the five toes. It supports the arch of the foot, and when it becomes inflamed and compromises that arch, chronic pain is the result.

It's not just a foot issue. The fascia exist throughout the body and also have biochemical roles.

Lee's journey started with a research paper on lower-back pain, where she noticed the researchers had observed something odd: the patients' fascia looked like those of diabetics. There were unusual calcium deposits throughout the tissue, which she later saw in her own patients.

The area of greatest concern was the Grand Central Station of the entire back: the thoraco-dorsal fascia. This fascial sheath connects prime movers like the lats and the glutes in the lumbar area, and problems in Grand Central can cause pain almost anywhere. Fascia are masterful at misdirection. Fascial slings can connect areas like the right shoulder to the left lower back, and pinpointing the actual problem requires a Sherlock Holmeslike ability to connect seemingly unconnected dots, often outside of the body.

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Just one example from diet: Lee had come to realize the importance of eating nutrient-dense animal foods with adequate fat-soluble vitamins (A, D, E, and K) to restore function in chronically inflamed tissues with abnormal calcium deposits.

Now, Lee was using me to test her latest and greatest: biopuncture.

Coined in 1991 by Jan Kersschot MD, a Belgian physician, "biopuncture" involves shallow injections of different substances, including Traumeel, zdeel, and lymphomyosot. Traumeel is typically used for acute inflammation from sports injuries, and lymphomyosot is utilized for lymphatic drainage in chronically swollen or congested tissue. Traumeel has been shown in some peer-reviewed journals to shorten recovery time from acute sports injuries and inhibit the secretion of immune mediators (IL-1B and TNF-alpha) that are a.s.sociated with tissue damage and increased inflammation.

Though biopuncture solutions aren't diluted to the extent that they contain no active product (like most homeopathic medicine), they are diluted and referred to as "microdoses." Lee used both Traumeel and lymphomyosot in my treatments.

In addition to the drug treatments, we also tested a saline solution with 20% dextrose. It was just like prolotherapy but with shallower injections.

The results of dozens of "baby jabs" with a small 30-gauge half-inch needle were amazing.

Twelve hours after the first treatment of both infraspinatus muscles, I had zero pain at the rear of either shoulder. I had suffered through persistent pain and soreness at the back of both shoulders for more than six years, and one 15-minute session fixed both of them. To date, no pain has returned.

The biopuncture was repeated for the right Achilles tendon, with similar results.

I think the mechanisms of action, while unclear, could be different for different locations. In the case of the infraspinatus, it seemed to be mechanical: the breakdown of calcium deposits with a needle, much like hacking at ice on your windshield. For the Achilles tendon, Lee hypothesized that it was some form of cutano-muscular or cutano-neural response.

Given their homeopathic origins, I remain skeptical of lymphomyosot and, to a lesser extent, Traumeel. But, given the minimal downside of biopuncture and the results I've experienced, I would recommend testing biopuncture before prolotherapy or PRP. For most musculoskeletal problems, a series of four to eight injection sessions are recommended.

TOOLS AND TRICKS.

This chapter will encourage a slew of con artists to become self-proclaimed experts. Though you might miss some good pract.i.tioners, I suggest focusing on those who were treating patients before this book was first published in December 2010.

Vibram Five Finger and Terra Plana Shoes (www.fourhourbody.com/vibram, www.fourhourbody.com/terra) These are the two brands of shoes I used to eliminate low-back pain. The Vibram Five Fingers are ideal but look like gecko feet. The Terra Plana Vivo Barefoot shoes, on the other hand, can double as dress shoes without anyone noticing that the soles are practically nonexistent. These are the two brands of shoes I used to eliminate low-back pain. The Vibram Five Fingers are ideal but look like gecko feet. The Terra Plana Vivo Barefoot shoes, on the other hand, can double as dress shoes without anyone noticing that the soles are practically nonexistent.

Healthytoes Toe Stretchers (www.fourhourbody.com/toe-stretch) These toe stretchers are like soft bra.s.s knuckles for your toes. They help restore natural toe spread and relieve pain from overlapping toes and toe drift. Start with five minutes each evening.

Active Release Technique (ART) Pract.i.tioner Database (www.activerelease.com) Use this site to find local ART specialists. Use this site to find local ART specialists.

Finding a Prolotherapy Pract.i.tioner Here are the three organizations recommended by those I trust in the field: Here are the three organizations recommended by those I trust in the field: Hackett-Hemwall Foundation (HHF) (www.hacketthemwall.org)American Academy of Orthopedic Medicine (AAOM) (www.aaomed.org)American College of Osteopathic Sclerotherapeutic Pain Management (the old term for "prolotherapy") (www.acopms.com) ChiroMAT (www.chiromat.com) Founder of the AMIT technique, Craig Buhler (aka "Dr. Two Fingers") has helped elite-level athletes from the NBA, NFL, and PGA to maximize their performance. Founder of the AMIT technique, Craig Buhler (aka "Dr. Two Fingers") has helped elite-level athletes from the NBA, NFL, and PGA to maximize their performance.

Muscle Activation Technique (MAT) Specialists (www.fourhourbody.com/mat) If you can't get to Utah to see Dr. Craig Buhler, use this site to find a MAT pract.i.tioner in your area. Though there is some contention between groups about the best technique, this organization provides the widest certification and is thus most accessible. If you can't get to Utah to see Dr. Craig Buhler, use this site to find a MAT pract.i.tioner in your area. Though there is some contention between groups about the best technique, this organization provides the widest certification and is thus most accessible.

Southern California Orthopedic Inst.i.tute (www.scoi.com) Dr. Stephen Snyder at SCOI has developed many new techniques and technologies for arthroscopic shoulder surgery. Referred to me by friend and fellow patient Scot Mendelson, who bench-presses more than 1,000 pounds. Dr. Stephen Snyder at SCOI has developed many new techniques and technologies for arthroscopic shoulder surgery. Referred to me by friend and fellow patient Scot Mendelson, who bench-presses more than 1,000 pounds.

Video of My Reconstructive Shoulder Surgery with Dr. Snyder (www.fourhourbody.com/surgery) The pre-surgery shoulder dislocation while I'm sedated is disgusting. Fun watching if you enjoy YouTube videos of folks face-planting off of Swiss b.a.l.l.s, etc. The pre-surgery shoulder dislocation while I'm sedated is disgusting. Fun watching if you enjoy YouTube videos of folks face-planting off of Swiss b.a.l.l.s, etc.

Biopuncture: Common Questions and Answers (www.chiromedicalgroup.com/biopuncture) Overview of Biotensegrity (www.fourhourbody.com/biotensegrity) This explains the fascinating functions of fascia. Steven Levin, an orthopedic surgeon, explains how the principles of tensegrity seen in R. Buckminster Fuller's geodesic domes apply in the human body, with bones acting as the compressive elements and the soft tissues as the tension elements. If you are at all geek-inclined, read "The Importance of Soft Tissues for Structural Support of the Body." It's outstanding. This explains the fascinating functions of fascia. Steven Levin, an orthopedic surgeon, explains how the principles of tensegrity seen in R. Buckminster Fuller's geodesic domes apply in the human body, with bones acting as the compressive elements and the soft tissues as the tension elements. If you are at all geek-inclined, read "The Importance of Soft Tissues for Structural Support of the Body." It's outstanding.

Egoscue (www.egoscue.com) Egoscue is a postural therapy program with 24 clinic locations worldwide. The program is designed to treat musculoskeletal pain without drugs, surgery, or manipulation. It was instrumental in reducing and eliminating my back pain. Egoscue is a postural therapy program with 24 clinic locations worldwide. The program is designed to treat musculoskeletal pain without drugs, surgery, or manipulation. It was instrumental in reducing and eliminating my back pain.

Atlas of Human Anatomy by Frank H. Netter ( by Frank H. Netter (www.fourhourbody.com/netter) This is THE most beautiful and (mostly) comprehensive anatomy book I've ever encountered. It was suggested to me by multiple doctors, including Dr. Lee Wolfer, who described this book thusly: "Netter is single-handedly responsible for the anatomical knowledge of the majority of doctors out there. He just missed the fascia and complexity of ligaments." I also own the flashcards based on the book, which are designed for medical students. This is THE most beautiful and (mostly) comprehensive anatomy book I've ever encountered. It was suggested to me by multiple doctors, including Dr. Lee Wolfer, who described this book thusly: "Netter is single-handedly responsible for the anatomical knowledge of the majority of doctors out there. He just missed the fascia and complexity of ligaments." I also own the flashcards based on the book, which are designed for medical students.

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End of Chapter Notes 1. Similar to the pioneering Hackett-Hemwall protocol of prolotherapy, often referred to as the "sewing machine" approach. Similar to the pioneering Hackett-Hemwall protocol of prolotherapy, often referred to as the "sewing machine" approach.

HOW TO PAY.

FOR A BEACH.

VACATION WITH.

ONE HOSPITAL.

VISIT.

I wish we were all naked all the time. I have always believed it's what's underneath that counts.-Celine Dion Edwin loved Celine Dion and seemed happy to tell someone about it.

During his radiology training in Iowa, he'd seen Stone Cold Steve Austin at the WWE, one dream fulfilled, but Celine Dion was still on his to-see list.

"We have a lot to do! Please don't move. Here we go..." Edwin was also my MRI technician and companion for the next four hours. It was a long time to be horizontal, but the surroundings were beautiful. Hospital Metropolitano Vivian Pellas, a pristine private hospital in the center of Managua, Nicaragua, couldn't have been nicer.

I'd come to Nicaragua almost three weeks earlier to focus on writing and world-famous surfing. The Kiwi, of Perfect Posterior fame, and I had rented a hillside villa with a pool overlooking the ocean. To skip the crowds at the beaches, we chartered a boat with a captain to the best secluded surf spots up the coast. En route home, the captain also helped us catch and clean fish our private chef could prepare for dinner.

Now, it was 12 hours before my return flight to San Francisco, and I was going to pay for the whole thing with one trip to the hospital.

An Introduction to Medical Tourism Let's look at the math to see how this is possible. First, the per-person expenses in Nicaragua: EXPENSES.

Round-trip Orbitz airfare to Nicaragua from San Francisco (one stop in Houston)-$385 + taxesChartered boat (per trip per person)-$20First week housing ($2,000 per week for nine people in a 14-bed villa owned by a former NBA player)-$222 per weekSecond week housing onward (gorgeous two-bed villa closer to downtown [www.palermohotelandresort.com])-$129 per nightLand Rover rental (per person)-$140 per weekTotal for two and a half weeks, excluding food-$1,812 I've excluded food above to show costs above what I would have spent in the U.S. anyway, as I eat out at least two times a day in San Francisco. Here is the grand total:

Total for two and a half weeks, including food and wine (+$600): $2,412 So how do we get back to break-even and make the trip, in effect, free?

MEDICAL SAVINGS.