Welcome to Apple Creek Sports Medicine


Slipped Disc vs. Disc Herniation vs. Disc Bulge By Dr. Liv Chiarelli

Slipped Disc vs. Disc Herniation vs. Disc Bulge

We’ve all heard talk about the above terms but what is the difference and which one do you have?


First let’s talk about what a disc actually is.  Discs act as cushions that sit between the spinal vertebrae (bones of the spine) to help absorb shock.  They are made up of a tougher cartilaginous outer layer known as the annulus fibrosus and a softer cartilaginous inner layer known as the nucleus pulposus kind of like a jelly donut.

Like all other tissues in your body the spinal discs respond to the stresses placed upon them.  When the outer layer of the disc, the annulus, becomes weak due to stress it can cause a portion of the disc to bulge.  Think of this like placing a bit of pressure on the jelly donut and watching it slightly change shape.


A disc herniation occurs when the stresses placed upon the spinal discs are enough to cause the softer inner layer, the nucleus, to displace beyond the normal borders of the disc in a focalized fashion.  Think of this like placing a lot of pressure on the jelly donut and watching the jelly displace out of the hole in the donut.

Herniated and bulging discs can occur throughout the entirety of the spine, however, they are most common in the low back as this is where there is more pressure and therefore more stress.  Finally, it is best to remember that not all herniated or bulging discs cause painful symptoms but those that do can generally be managed through conservative treatment, including manual therapy, exercise, education, and pain or anti-inflammatory medication.

Dr. Livia Chiarelli



Back Pain and Breathing Dysfunction by Nejin Chacko


The ability to breath in (inspiration) and out (expiration) is driven by the pressure difference between the lungs and the atmosphere. This requires contraction and relaxation of the diaphragm and the muscles in the thorax.  During normal relaxed breathing, contraction and relaxation of the diaphragm and the intercostals muscles (found between the ribs) cause most of the pressure changes that result in inspiration and expiration. The ability of the thoracic wall to stretch and recoil while under pressure influences the process of breathing. In normal inspiration an increase in the volume of the thoracic cavity is produced by the downward movement of the diaphragm and external intercostal muscles which move the ribs upward and outward, causing the rib cage to expand. The expiration in normal breathing is passive caused by the recoil resulting from the elasticity of the lungs. Additional muscles such as neck muscles are used during forced inspiration and abdominal and internal intercostals muscles are used during forced expiration. The respiratory rate is controlled by the respiratory centers located within the brain and the chemoreceptors present in the periphery. Although changes in pH levels and a large drop in blood oxygen levels can influence breathing, the major factor that stimulates the breathing rate is the concentration of carbon dioxide in the blood. The increase in breathing rate during exercise is thought to be influenced by the psychological, motor neuron and proprioceptor inputs.


In healthy subjects the diaphragm plays the dual role of spine-stabilization and respiration. During movements of the spine or extremity, the back extensors, diaphragm, pelvic floor and abdominal wall muscles activate synchronously. Diaphragm contributes to an important role in spinal stability through modulating the intra-abdominal pressure when the spinal stability is challenged. Although the diaphragm and abdominal muscles activate in opposition during respiration, a coordinated contraction of these muscles provide respiration and control of the spine simultaneously when in need co-ordinated by the central nervous system. It is described that dysfunction in one function, either respiration or spinal stabilization can negatively impact the other. Studies have also shown that a coordinated contraction across various sections of diaphragm is absent in patients with chronic low back pain during body movements that demand spinal stabilization.


Various studies have reported a significant correlation between low back pain and breathing dysfunction. A breathing dysfunction refers to altered breathing patterns which include simple upper chest breathing to hyperventilation. An altered respiration can alter the respiratory chemistry and thus can also influence the tissue oxygenation and electrolyte balance altering body functions including brain and skeletal muscles. Several studies have reported improved function in short term follow-ups with breathing exercises in chronic lower back pain patients.


Signs of dysfunctional breathing

Breathing pattern dysfunctions may be present along with chronic back pain if you experience symptoms like restlessness, frequent sighing, poor breath-holding times, poor expansion of lower thorax on inhalation, rise of shoulders on inhalation, rapid breathing rate or difficulty with abdominal breathing.


A few strategies to correct your breathing pattern

  • Correcting an upper chest breathing pattern: Start with a lying position with one hand on the chest and the other over the stomach. Take a deep breath in through the nose, ensuring the stomach rises first (not the chest). Repeat 5-10 slow breaths per minute for 5 minutes each day.
  • Gradually try the above in other static positions such as sitting and standing and progress further by integrating diaphragmatic breathing into your daily tasks and exercises.
  • Most over-breathing involves too much in-breath and not enough out-breath which leads to not fully releasing the inspired air. Try breathing-in for a count of 3 and breathing out for a count of 5.
  • Allow a short pause between each breath.
  • Following an out-breath don’t reach for the next in-breath, rather simply allow the body to initiate it to come.
  • Use a mirror to correct any unwanted movements and muscle activation of the upper chest and neck.
  • Avoid negative thoughts about breathing or anything that can lead to anxiety.



Lise Hestbaek, Charlotte Leboeuf-Yde, Claus Manniche, DrMedScc . Is low back pain part of a general health pattern or is it a separate and distinctive entity? A critical literature review of comorbidity with low back pain. J Manipulative Physiol Ther. 2003 May; 26(4):243-52. (2A)

Kolar P, Sulc J, Kyncl M, et al. Postural function of the diaphragm in persons with and without chronic low back pain. Journal of Orthopedic and Sports Physical Therapy. 2012; 42 (4): 352-62.

McLaughlin L., Goldsmith, C., Coleman, K. Breathing Evaluation and retraining as an adjunct to manual therapy. Manual Therapy 16 (2011) 51-52

McLaughlin L. Breathing Evaluation and Retraining in Manual Therapy. JBMT 2009; 13:276-282

Beeckmans et al. “The presence of respiratory disorders in individuals with low back pain: A systematic review”, Manual Therapy. 2016; Vol 26, pag 77–86.

Hestbaek L1, Leboeuf-Yde C, Manniche C. Is low back pain part of a general health pattern or is it a separate and distinctive entity? A critical literature review of comorbidity with low back pain, J Manipulative Physiol Ther. 2003 May;26(4):243-52.

Low Back Pain and Breathing Pattern Disorders. (n.d.). Retrieved from https://www.physio-pedia.com/Low_Back_Pain_and_Breathing_Pattern_Disorders#cite_note-18

Communication is the Key by Jordan Katz

Communication is the key!

When working with a physiotherapist, there are many factors that will help a patient in accelerating recovery.  The type of injury or condition, the skill of the therapist, and the amount of time and effort put into rehabilitation exercises, are a few of the key factors. By far, however, the most important factor is communication.  Throughout my years as a therapist I have found this to be extremely accurate, and the evidence backs it up. When patients and therapists are able to communicate openly and effectively, results are better and come about more quickly.

How is it important?

Of course, there are many factors to communication and many ways that communication can affect the outcomes of a single treatment session, or the entire course of treatment.  Communication is a 2 way street, and requires all parties to be involved and comfortable. From the initial interactions between the therapist and patient, it is important to develop a rapport.  The therapist must be able to make the patient comfortable and allow them to express their concerns about their situation. Therapists need to encourage the patient to expand on the kind, location, and intensity of the pain, how their individual situation is affecting them, and what the expectations are from treatment.  The therapist must actively listen and engage with the patient, using effective questioning to help the patient expand on/or pinpoint the problem, in order to truly understand what is happening and how it is affecting them personally. This will allow the therapist to gain more insight and to diagnose the situation more effectively.  This open communication also sets up a framework for empowering the patient so that they are comfortable enough to openly express how they are feeling throughout their treatment course.

How it can help patients

Upon completion of the Initial Assessment, it is imperative that the therapist takes the time to explain the findings of the assessment to the patient.  The therapist must discuss the diagnosis, what it means, its impact, and how s/he plans on addressing the situation. In many disciplines, practitioners give a patient a 1 or 2 word, sometimes “scary” or ominous sounding diagnosis, often steeped in medical jargon, which the patient may not understand.  This is often followed with a treatment prescription, with no input as to why or how it may help. I believe, as do most of my colleagues at Apple Creek, that by taking the time to explain to the patient what has been diagnosed, why it has been diagnosed, how it has occurred and how we plan to address it, that the patient is again empowered and understands their role in the rehabilitation process, and why it is imperative for them to fulfill their role to achieve greater success.

With a thorough understanding of what is going wrong, why it has occurred, and a plan developed in concert with the therapist, the patient is handed more tools to help them achieve success.  Hopefully they have enhanced confidence in their therapist and feel as though they are working together to improve. As therapy goes on, this will help the patient feel comfortable to discuss interventions that are working well and those that may not be working as well.  Patients will understand why it is important to do their exercises and have a better understanding of how to do them correctly. Hopefully patients won’t feel ashamed or embarrassed to admit any confusion or forgetfulness of exercises. With good open communication, the therapist and patient can adapt the program to suit the needs of the patient at any time, and both parties can understand how these changes may affect outcomes (be it positively or negatively).

I have worked diligently over my career to develop my communication skills with my patients. I strive to work as a team with every individual and educate them in ways that they can understand, using non-medical jargon. Over time, I have formulated many ways to explain conditions or biomechanics that are meaningful to the individual, and I attempt to foster strong relationships with my patients.  By doing so, have been rewarded with many great success stories and the development of incredible patient-therapist relationships over the years.

I look forward to being able to communicate to you what may be occurring in your situation and helping you succeed in achieving optimal function once again.


Jordan Katz HBa(Kine), MScPT
Registered Physiotherapist

Delayed Onset Muscle Soreness and Massage by Sean Li (RMT)

Have you ever worked out, went to sleep, and felt sore the next day? Or the day after that? That was because of something called Delayed Onset Muscle Soreness (DOMS). Massage can help increase the circulation to the area and decrease the overall recovery time!

What is DOMS?

DOMS is a dull, achy pain that takes a little bit longer to set in after a workout  or exercise.

The muscle soreness usually comes with tenderness (to the touch) and stiffness. DOMS also usually sets in 6-48 hours after exercise and can last up to 7 days.  The timeline for DOMS varies from person to person.

What Causes DOMS?

The cause of DOMS used to be the belief that “lactic acid” was a toxic metabolic waste and that acid built up in the muscle. This caused the body to perceive pain at the affected area.

DOMS is now more commonly believed to be caused by micro trauma or micro tears in the muscle. The body then starts the inflammation process to bring blood and nutrients to help repair the damaged tissue.

What can I do?

There are a variety of things you can do for DOMS, most of which involve increasing blood flow

to the area. Ways to do that are:

  • Gentle massage
  • Stretching
  • Hot baths/Saunas/Epsom salt baths
  • Foam rolling
  • Low intensity training


When should I go seek medical advice?

  • If the pain started during exercise
  • The pain feels like it’s more than just muscular
  • Swelling in the joints
  • Pain doesn’t feel like its resolving itself

So if you’re feeling sore, do yourself and your body a favour and get a massage!

Book a massage with Sean Li, Registered Massage Therapist today at Apple Creek Sports Medicine Centre today!

Osteopathy and Headaches – can it help? by Sarah Shaw, RMT

As discussed in a previous blog post, it is estimated that 47% of the world’s population has a headache at least once a year. For many of my patients, headaches are something that happen either a few times a month, week or even daily in some cases. Although massage therapy treatment, chiropractic, athletic therapy and physiotherapy are great options and may have success, many people are unaware of the positive impact that Osteopathic Manual Therapy can have on headaches.

A systematic review was published in March of 2017 looking at Osteopathy for primary headache patients (Cerritelli et al., 2017). A systematic review collects the results of all studies that have been done on a specific topic, analyzes the data and summarizes the existing research. As a result, they are beneficial to look at when generating a research based opinion.

Role of Osteopathy on Headaches

Primary headaches are considered to be a headache that is due to a headache condition itself opposed to another cause (such as sinus headaches). The types of primary headaches are migraines, tension headaches and cluster headaches. The review concluded that the positive effect that osteopathy has on headaches could be related to osteopathy’s influence on the autonomic nervous system. More specifically, it plays a role in increasing a patient’s parasympathetic tone (muscles in a relaxed state) and decreases inflammatory substances in the body.

The main outcomes seen in the studies reviewed were that Osteopathy was effective in reducing the number of migraine episodes in a 6-month period, there was significantly improved pain scores (less pain with migraine), lower frequency of headaches resulting in the reduction of medication use over time, and a significant increase in the number of headache-free days per week.

In conclusion, the review suggests that Osteopathic treatment can reduce both the frequency and severity of future headaches. Additionally, it is beneficial in the management of headaches. So, YES, osteopathic treatment can also help get you relief from headaches and manage your headache pain.

To inquire more about osteopathy, headaches and how osteopathy may benefit you, or if you have specific questions you can contact sarah@applecreeksports.com, brock@applecreeksports.com or john@applecreeksports.com

By: Sarah Shaw RMT, 3rd Year Student at Canadian College of Osteopathy

What is Kinesiology Tape? by Stephanie Loy Son, CAT(C)

You’ve probably seen it everywhere – at the Olympics, at your child’s track meet and/or even on your best friend. It’s that long piece of sometimes fluorescent coloured tape that sits on an athlete’s shoulder, leg or even abdomen. What is it, you ask? It’s kinesiology tape or more commonly referred to as KT Tape based on the most used brand. Other brands include Kinesio Tape, Rock Tape, Spider Tech and so on. Here at Apple Creek Sports Medicine, our practitioners often utilize this tape before sending a patient home. This post will explain both when and why we use this tape in our clinic.

Kinesiology tape came into popularity back in 2008 at the Beijing Olympics where it was commonly seen on beach volleyball, and other athletes.1 It was developed by a Japanese chiropractor named Kenzo Kase in the 1970’s, who originally used it to help with lymphatic drainage (i.e., swelling).1 Since then it’s use has been expanded to help with:

  • Muscle facilitation and inhibition
  • Pain relief
  • Lymphatic drainage (i.e., swelling)
  • Proprioception (i.e., body awareness)

The question is, does it actually do what it’s supposed to? Is it providing the feedback an athlete or patient needs or is it placebo based?

Kinesiology tape is an elastic tape with an adhesive backing that has the ability to stretch to 20-40% of its original length.1 It’s thickness mimics that of human skin which prevents restrictions in range of motion, and allows for periods of longer use.2 The belief behind the tape is that it stimulates the skin and the underlying receptors to activate the muscle(s).3 It also works to pull the skin from the underlying connective tissue, which opens up the space in-between allowing greater circulation of blood and lymphatic drainage.4 Overall, the research on kinesiology tape has shown that it has a minimal effect on muscle strength, and that there is not enough evidence to support the claims of reduced pain, improved proprioception or muscle activity.2 In terms of it’s original use of lymphatic drainage, the literature is very minimal and focuses on swelling in cancer patients.2 There is little research on swelling stemming from contusions, which is what we mainly see in our clinic.

While the research backing kinesiology tape is minimal and demonstrates little benefits, what an athlete or patient reports when they wear it is of greater value. Furthermore, research has shown that there is no negative effect on athletic performance with the application of kinesiology tape.1 When it comes down to the performance of an athlete or improving the posture of an office worker, applying a tool which provides active feedback and has no ascertainable negative effects only works to help our client.

Tips on Making Your Kinesiology Tape Last

  1. After a shower, pat the tape dry instead of rubbing it
  2. When the tape starts to fray or peel, trim the edges with a pair of scissors
  3. If you notice any redness or itchiness underneath or around the tape, remove it immediately as you may be allergic to the adhesive


1Drouin JL, McAlpine CT, Primak KA, Kissel J. The effects of kinesiotape on athletic-based performance outcomes in healthy, active individuals: a literature synthesis. J Can Chiropr Assoc. 2013;57(4):356-365.

2Williams S, Whatman C, Hume PA, Sheerin K. Kinesio taping in treatment and prevention of sports injuries: a meta-analysis of the evidence for its effectiveness. Sports Med. 2012;42(2):153-164.

3Aarseth LM, Suprak DN, Chalmers GR, Lyon L, Dahlquist DT. Kinesio tape and shoulder joint position send. J Athl Train. 2015;50(8):785-791.

4Kase K, Hashimoto T, Tomoki O. Development of kinesio taping perfect manual. Kinesio Taping Association. 1996; 6-10: 117-118

Knee Pain and Glute Med

Hey Guys,

So lately I have been seeing a lot of knee pain and I need to address it. Most of the time the knee pain that I see is coming from weak muscles of the hip, especially when the knee pain “comes from nowhere” or “I never did anything”. The lateral hip muscles (gluteus medius), help to stabilize the pelvis which will control the the knee. If the hip loses its strength, you are unable to absorb forces properly (these forces being gravity). Now, the knee has to adapt because gravity is still being placed on your body and usually that adaptation will turn into pain. So here is how you can test your knee to see if you have a weak gluteus medius:

If you do have a weak glute med (pronounced gloot meed) then go through these simple yet effective exercises:

Perform them 2 times a day for 3 sets of 10 and watch your knee pain disappear.

If you want to follow me on social media

Instagram: @nick_the_AT

Twitter: @nicktheAT

Youtube: Nick the AT

Nicholas Halkidis

Core Fundamentals -Jeannette Quach

Whether it is back, knee or shoulder pain, the other common question I get is “how do I get rid of this pain and prevent it from occurring again?”. If you look back to my previous article about Repetitive Stress Injuries – Why & How, I discuss the 3 main reasons why these injuries occur. Fast forward to the present time where you are now functional and moving pain free. 

What’s next?

The answer is as simple as understanding that the stretching and strengthening must continue – especially core strength. Core strength is very underrated. It is not about achieving that six-pack you’ve always wanted for beach days and it is definitely not about who can do the most sit ups. It is about the foundation of your movements and the centre of gravity you hold to keep you stable. Your core is the one stable body that supports the movements coming from your limbs. For example, to throw a ball you obviously need to use your arm in order to wind up and release the ball. However, your core is what generates the force that gets translated to your arm to release the ball further and with more accuracy. Another great example for our Canadian winter weather is shovelling snow. If you don’t brace your core as you are shovelling and help with your legs, you are setting yourself up for some functionally-limited back pain the next day and possibly even a disc bulge. 
Your global core muscles include your typical rectus abdominals (your 6-pack), erector spinae, external obliques and quadratus lumborum. Your local core muscles are the smaller deeper muscles such as your transverse abdominals (your belt), internal obliques, multifidus, transversospinalis and the pelvic floor muscles. Most people fire their global muscles quite easily as they assist our major movements. However, the local core muscles group are the muscles that provide stable support of the spine and pelvic bones and should be fired first. 
Start your exercise regime with proper core strengthening to prevent injuries from occurring or re-occurring and to build a stronger you!
Book an appointment with Jeannette for core activating exercises and prevent yourself from being a victim to the dreaded back pain.

Don’t let the injury bug bite your team before playoffs

Hey Coach,

Has your team been affected by the injury bug yet?  With playoffs just around the corner, we want to help your players get back in the game quickly!

Quick and accurate treatment after an injury can make a huge difference in games lost.  The sooner an athlete gets started with injury rehabilitation, the faster they can return to play.  Direct them to Apple Creek Sports Medicine Centre and we will get them assessed within 24 hours, begin treatment, and give them a realistic time frame as to when they may be able to return to play.
With the right game plan for sports injuries, from early assessment to full functional rehabilitation, we can often safely accelerate an athlete’s return to play.

If your players are injured at a sanctioned event, the cost of treatment should be covered through the player’s family extended health plan or through the organizations insurance plan.  Check out the links below if a player does not have extended health care:

Hockey Insurance Info

Ringette Insurance Info

Basketball Insurance Info

Volleyball Insurance Info

If you have any questions about any of the information in this letter, please contact Nick: nick@applecreeksports.com, Stephanie: stephanie@applecreeksports.com  or call us at 905-475-0484. We would be happy to set up a time to come to your practice to meet with the coaching staff or to talk to players/parents regarding acute injury treatment, concussion management and how to stay injury free throughout the season.

Good Luck with the rest of your season, we would be happy to help!

Kindest Regards,
John Sage CAT(C)       Stef Moser CAT(C)
Clinic Director               Clinic Director

To use the insurance, print the respective form, have it completed by a physician or qualified person as necessary, then send in the receipts to claim any expenses incurred at Apple Creek Sports Medicine Centre.

Concussion Management Centre

Concussions are a common brain injury and are often difficult to diagnose and treat. Apple Creek Sports Medicine Centre is proud to be a Complete Concussion Management Centre for Markham and the official ImPACT Concussion Testing Centre for Markham and the surrounding areas.  The value of baseline testing is having baseline measurements before a concussive incident occurs. It is not mandatory but suggested.

Apple Creek Sports Medicine Centre staffs 5 Certified Athletic Therapists who would be facilitating these programs with your teams.  All 5 therapists have experience with all levels of sports.  Stefanie Moser has worked as the head athletic therapist for the National Women’s Hockey team and has traveled internationally with Hockey Canada for many years. John Sage has been the Athletic Therapist for the Markham Waxers Midget AAA and Stouffville Spirit organizations. He has also traveled internationally with Baseball Canada as part of the medical staff.  Jeannette Quach has worked with the Toronto Aeros Jr. AA, provincially with field hockey and nationally with Ultimate Frisbee.
Nicholas Halkidis, played AAA hockey in Markham and now works with the North York Rangers and Baseball Canada.  Finally, Stephanie Loy Son has experience with provincial martial arts, badminton and cheerleading.

A New Year and a New You – Dr. Chiarelli

New Year, New You

Around the new year there is a lot of talk about resolutions and goal setting in order to make improvements in our lives in some way. The most common resolutions include staying fit and getting healthy with almost 70% of people making some type of resolution in those areas. Despite the good intentions, approximately 80% of people fail at keeping their new year’s resolution by the 2nd week of February.


By making your resolutions realistic, there is a greater chance that you will keep them throughout the year and incorporate healthy behaviour into your everyday life.  Here are a few tips when making your resolutions:


  • Start Small – Make resolutions that you think you can keep. If you want to increase your physical activity level aim for 3 or 4 days a week instead of 7.
  • Change one behaviour at a time – Unhealthy behaviours develop over time and thus reversing them will take time also. Begin my making one small change a time as to not get overwhelmed.
  • Set SMART goals – When creating your resolutions make sure they are Specific, Measureable, Attainable, Relevant, Time Bound goals
  • Talk about it – Share your experience with family and friends in order to maintain accountability. Consider creating a group of friends or co-workers with the same resolutions to help you achieve yours.  Search the app store on your smart phone for applications that allow you to share your goals with fiends and keep each other updated on your progress.
  • Write it down – The physical act of writing down a resolution makes it realistic and tangible, and it gives you no excuse for forgetting about your goals.
  • Don’t beat yourself up – Remember that minor missteps when reaching for your resolutions are normal. Don’t give up completely because you may have had a small set back, resolve to recover from your mistakes and get back on track.

And at the end if your resolutions don’t work out, well there’s always next year.

Written by Dr. Livia Chiarelli – should you need any support in your goals, Liv practices at the clinic Monday – Friday.  Call for an appointment now! 905-475-0484