The Core Principles of Evidence Based Medicine


The core principles of evidence-based medicine dictate that relevant research, the practitioner’s clinical experience, and the patient’s values all need to be considered when determining the best course of action in any given clinical scenario. Because clinical experience and a patient’s values are considered subjective variables, clear communication and understanding between the practitioner and patient is crucial. Appraising and interpreting relevant research, however, offers a key objective component to consider in the clinical decision-making process.

When it comes to joint pain, we often think of injections or surgery as our only options, however, it is important to understand that the bio mechanics of a joint, or the way a joint functions, is heavily dependent on structures that are adjacent to it. Think of the nerves in the muscles, tendons, and ligaments that relay messages to and from the brain about that joint. Knowing this, it is not surprising that the relevant research around managing many musculoskeletal conditions is to employ what is known as a ‘multi-modal’ approach to treatment. This means that the best outcomes are achieved by utilizing a variety of treatment options, including addressing changes to fascia, muscles, and tendons surrounding a joint, in addition to working through an individualized strengthening program to re calibrate or rehabilitate the function of that joint, and perhaps even protecting it from further damage with a brace.

In applying these concepts, the key to successful outcomes at Elite Sport Performance and the Knee Clinic is our three-pronged approach to treatment: treat the problem, strengthen the area, and avoid or modify offending activities.

Dr. Arif Karmali

BSc(Kin), DC



What does it mean to be a Chiropractic Sport Specialist?

By definition “chiropractic is an evidence-based, non-invasive, hands-on health care discipline that focuses on the musculoskeletal system.” – Ontario Chiropractic Association

Chiropractors treat a large range of maladies related to the spine, pelvis, nervous system and joints. After a thorough patient history and physical exam, a  chiropractor may use a combination of treatments, manipulations, hands on therapies, exercise prescriptions and lifestyle counselling. A chiropractor is indisputably an integral part of our primary healthcare team.

So what makes a Sport Specialist Chiropractor stand out?

Sport specialist chiropractors are highly educated and uniquely trained to provide expert assessment, diagnosis, and management of musculoskeletal conditions. In addition to a health science or kinesiology undergraduate degree and 4-year Doctor of Chiropractic degree, the intensive post-graduate sports sciences fellowship can take an additional 4 years to complete. With over 1500 hours of field work, academic focus on exercise physiology, sport nutrition, sport psychology, radiology, advanced imaging, rehabilitation, sport specific research, acute and chronic injury management, and sport administration training, the sports sciences fellowship provides the most extensive sports specialty training in the chiropractic profession.


Dr. Arif Karmali

Strength Training and Knee Pain

With Strength comes stability and with stability always comes less pain.

If you have spent any amount of time in our clinic, this is something you have more than likely heard. Dr Karmali shares a little on what makes stability so important to the health of our joints.

“When it comes to maintaining the long-term health of any joint in our body, stability plays a critical role. Take for example, the knee.
The knee joint is the largest and most superficial joint, primarily operating as a ‘hinge’, allowing for bending and straightening of the leg. These hinge movements are combined with gliding, rolling, and rotation, which add to the functional complexity of the knee. Despite being well constructed, the knee joint is relatively vulnerable mechanically because of the in-congruence of its articular surfaces, which can be likened to two balls laying on a warped tabletop.

With that thought in mind, imagine if we didn’t have any ligamentous or muscular control to hold things together… We wouldn’t have a very good knee and understandably, be more prone to injury or accelerated joint degeneration. It is with this notion that ensuring the integrity of joint-specific ligaments as well as adequate and timely neuromuscular control that we can provide our joints with optimal loading and force dissipation to maintain and even improve their longevity.”

Why Manual Therapy could be just what the Doctor Ordered

At Elite Sport Performance and the Knee Clinic, the key to successful outcomes is our three-pronged approach to treatment: treat the problem, strengthen the area, and avoid or modify offending activities. These three components are broad and can encompass a wide variety of decisions and actions. If we zoom in on the first component, ‘treat the problem’, we may encounter a number of treatment options for the problem we are endeavoring to manage, but how do we know what’s best for each patient? The principles of evidence-based medicine would dictate that that the related research, the practitioner’s clinical experience, and the patient’s values all need to be considered when determining the best course of action.

When it comes to joint pain, we often think of injections or surgery as our only options, however, it is important to understand that the bio-mechanics of a joint, or the way a joint functions is heavily dependent on structures that are adjacent to it. Think of the muscles, tendons, ligaments, and nerves that relay messages to and from the brain about that joint. Knowing this, it is not surprising that the related research around managing many musculoskeletal conditions is to employ what is known as a ‘multi-modal’ approach to treatment. This means that the best outcomes are achieved by utilizing a variety of treatment options, including addressing changes to fascia, muscles, and tendons surrounding a joint, in addition to working through an individualized strengthening program to re-calibrate or rehabilitate the function of that joint, and perhaps even protecting it from further damage with a brace.

Whether due to trauma or degenerative changes over time, cellular scar tissue, or fibrosis can accumulate and disrupt optimal function of a joint or tissue, and can even be a cause of pain. Using a variety of clinically-derived manual, or hands-on treatment protocols such as Active Release Techniques, Graston Technique, and other similar approaches, practitioners can improve the rate and quality of healing as well as aid in restoring optimal function to a joint or tissue.  This ‘hands-on work’ will often be prescribed as part of a patient’s individualized plan of management, and would fall under the ‘treat the problem’ component.

A Guide to Custom Knee Braces

Knee braces are used for a plethora of different clinical indications.  Being that we are the only private knee clinic in Alberta, we are intimately knowledgeable on these different braces and their appropriateness for various clinical conditions.


Patellar Stabilization Knee Braces

Knee braces can range from off the shelf to fully custom, can range in size from really quite small to relatively onerous, light weight to cumbersome, flexible to stiff.  The smallest and simplest knee brace that we offer in our clinic is a patellar stabilization brace called a Knee-O-Tracker.  This small neoprene brace has a buttress on one side that can be tightened or loosened in order to create stability to either the medial or lateral side of the kneecap, depending on which way the kneecap is prone to subluxing or even dislocating.  Relatively comfortable and able to be worn underneath most pants, it does a good job of decreasing the chances of recurrent subluxation or dislocation but is not strong enough to truly stop the dislocation incident, if appropriate forces are applied.


Mechanoreceptive Knee Braces

Next in the line of brace control is something called a GenuTrain by Bauerfeind.  This German company creates a woven, soft knee sleeve that is elastic in certain planes of motion and non-elastic in other planes of motion.  It is excellent at stimulating what are known as the mechanoreceptors, small sensors in the skin that make your brain more cognizant of the position of your knee relative to the rest of your body.  While they do not create true knee control, they do wake up the muscles in the area to a statistically significant degree and give people a greater sense of confidence during activities of daily living.  GenuTrain knee braces also come in a new osteoarthritic unloader version.  This unloader version takes the mechano-receptive fabric brace and adds BOA adjustable straps to it in order to create mechanical unloading to the medial or lateral compartment of the knee, depending on which way you wear the brace.  This brace is not custom but comes in six different sizes and so can be made to fit quite snugly.  A very comfortable brace, it again helps the patient feel more confident in their day-to-day activities.


Custom Meniscal / Cartilage Unloader Knee Braces

Moving up the scale of unloading control, we get to a brace made by Ossur called a Rebound Cartilage Unloader.  This unloader knee brace is custom made and is very svelte.  It can be designed to either unload the medial or lateral compartment and begins to unload from a 45-degree flexion knee bend, making it unique amongst unloader braces, which typically unload from 30 degrees of flexion to full extension. Its light weight and low profile make it an excellent option for thin or lean patients who have either acute or subacute meniscal damage postoperative meniscal repair or early degenerative changes.


Custom Osteoarthritis Unloader Knee Braces

The most common brace utilized in our clinic is the custom OA Unloader One made by Ossur.  This brace is the gold standard for medial or lateral compartment unloading.  It is thin, light weight, and custom fit down to the millimetre.  It is very comfortable and single-handedly has helped thousands of our patients either get back to or continue with activities that they are passionate about that they were not able to do without this brace.  In cases of bone bruises or impaction fractures, this brace helps to alleviate symptoms remarkably well and quickly.



Custom Ligament Knee Braces

In our opinion, the best and lightest custom ligament brace on the market is the CTI made by Ossur.  CTI originally stood for carbon and titanium, the materials with which this knee brace was comprised.  Both materials are vaunted for their strong mechanical characteristics and exceptional light weight.  Over the years, the CTI has undergone revision after revision and has become progressively better.  It is now a very light weight, preimpregnanted carbon fibre that is exceptionally strong.  Measured with attention to detail, it is accurate down to the millimetre, and consequently is very comfortable for the patient and exceptionally good at stopping any extraneous motions medially, laterally, anteriorly, or posteriorly of the shin relative to the femur.  It also stops any excessive varus and valgus loads, but it cannot stop internal torque.


A different version of the CTI is the CTI OA.  This particular custom brace has all the same features of CTI but can be built with a degree of unloading incorporated either laterally or medially depending on the particulars of the patient’s case.  Where the degree of unloading is adjustable in something like a rebound cartilage or Unloader One, in a CTI OA the degree of unloading is predetermined at the time of manufacture.


Insurance Coverage

Most people’s insurance companies will have coverage for non-custom knee braces and most insurance companies have a separate, distinct provision for coverage of custom knee braces.  Following a comprehensive history, physical examination and review of any appropriate imaging at our Knee Clinic, we are able when clinically indicated to write you a prescription that you can submit to your insurance in order to be reimbursed, often for 100% of the cost of the knee brace.  Some of these knee braces carry a one-year fit warranty so that if the patient’s changes, the laboratory will remake the brace from scratch for free.  Both Bauerfeind and Ossur have excellent reputations for standing behind their work and although they very rarely have manufacturing issues, if ever there is something that arises, they stand behind their products remarkably well, as do we.


Should you have any questions about your own knee or if you would like to bring in your current knee brace to see if it still fits, or needs adjusting, or perhaps needs to be replaced, please phone us at (403) 457-5633.

Our Approach to Knee Injections

Joint injections and musculoskeletal (MSK) injections are increasingly common in Calgary and indeed, across North America.  At both Elite Sport Performance as well as our private Knee Clinic, we utilize various injections when clinically indicated.  Joint and musculoskeletal injections can be done either blind or with the benefit of image guidance.  Various studies purport that blind injections into a joint have an accuracy of somewhere around 63% to 75%, while image-guided joint injections enjoy an accuracy of between 95% and 99%.  Unsurprisingly then, the popularity of image-guided joint injections is increasing.  There are still some ‘old-school’ physicians who claim to be able to do a blind injection with a high degree of accuracy, but the statistics do not support this approach.


When performing an image guided injection, the practitioner has the option of using a diagnostic ultrasound or a much more expensive piece of equipment called a fluoroscope.  A fluoroscope is effectively a live x-ray exposing the patient to a not-insignificant degree of radiation.  Diagnostic ultrasound, on the other hand, is non-irradiating.  With respect to fluoroscope-guided procedures, a small amount of dye is typically injected so that the physician can confirm that the needle placement is correct.  This is in part necessary because the fluoroscope does not show in great detail the soft tissues in the area in question.  Diagnostic ultrasound, on the other hand, does not require any dye injection and shows in considerable detail the soft tissues surrounding the target to the injective.


There is another less palatable reason for a doctor to use a fluoroscope for image guidance rather than a diagnostic ultrasound, and that is the ability to bill Alberta Health Services for a ‘surgical procedure’ for even the most basic injection.  This billing code allows the physician to bill Alberta Health Services over $600 for simply turning on the fluoroscope when a much less expensive, less dangerous ultrasound option exists.  Diagnostic ultrasound procedures are billed at a dramatically lower rate to Alberta Health and can also be utilized within a truly private clinic.  Compounding the disparity between these two procedures is the timeliness with which they can be done.  Image-guided joint injection by a physician using a fluoroscope currently is accompanied by a wait of weeks to months within the city of Calgary.  The same image-guided joint injection using a diagnostic ultrasound can often be done within one or two days.  This represents a significant cost-savings of time for a patient looking to have a procedure done sooner rather than later.  This timeliness, along with the different ethical approach in billing Alberta Health Services so much money for a simple procedure, is why there is quite a difference in pricing for certain injections within the city.


Ultimately, it is the patient’s prerogative which route they choose to take,  but consider asking the clinic which method of image guidance they use and ask yourself if costing the public system more than $600 extra really represents good value for you, your family, or your community.  Paying a little bit extra to have the procedure done privately in a timely fashion, using a non-irradiating guidance such as diagnostic ultrasound, can allow you to feel better both physically and morally.  For more information regarding this topic or to learn more about any of the injections that we offer within our clinic, please reach out at (403) 689-9889 or

Low Back Pain and Disability

Did you know that low back pain causes more disability than any other condition globally? As such, the development, or ‘pathogenesis’, of low back pain has long been investigated by research groups and programs. Most recently, the esteemed Drs. Injeyan, Injeyan, and Triano compared differences in inflammatory markers in the blood between asymptomatic individuals, and patients with non-specific acute or chronic low back pain. While there are limitations to every study, their results highlighted a distinct increase in pro-inflammatory mediators and a marked decrease in anti-inflammatory mediators in both groups of symptomatic patients when compared to asymptomatic individuals. Interestingly, a separate group in 2016 looked at the various effects of spinal manipulation and found that this technique may in fact activate naturally-produced anti-inflammatory mediators.

Inflammation and Diet

Did you know that localized inflammation in response to musculoskeletal injury is not only natural, but is essential to promote healing?  Damaged cells release chemicals within the inflammation which signals the body to initiate the repair process.  While some level of local inflammation is necessary, uncontrolled or persistent inflammation can cause more harm than benefit, resulting in additional tissue damage and prolonged recovery.  Substantial evidence now suggests that what we eat can influence the inflammatory response to both acute and chronic conditions.  Both pro-inflammatory and anti-inflammatory foods have been shown to affect the inflammatory response of the immune system to injury.  Limiting consumption of pro-inflammatory foods such as saturated and trans fats, refined sugars and carbohydrates, and processed foods, and increasing consumption of anti-inflammatory foods such as omega-3 fatty acids, colourful fruits and vegetables, olive and flax seed oils, and nuts, may not only help keep the inflammatory response in check, but may also protect healthy cells from inflammation caused damage.



Minihane, A., et al. (2015). Low-grade inflammation, diet composition and health: current research evidence and its translation. British Journal of Nutrition114(7), 999-1012.Tidball, J. (2005). Inflammatory processes in muscle injury and repair. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology288(2), R345-R353.

Inflammation and OA

Osteoarthritis (OA) was previously considered non-inflammatory. It is now well recognized that inflammatory mediators are produced and can be measured in joint fluids of patients with OA. This inflammation is a major risk factor in cartilage loss, pain, swelling, and stiffness. When management and treatment of OA consists of anti-inflammatory components, patients can improve their function and decrease pain levels. Platelet-rich plasma (PRP) is a cell therapy, that uses one’s own blood through joint injections, to reduce inflammation. Platelets are a high source of concentrated growth factors and inflammatory mediators. Platelets in PRP release many types of anti-inflammatory proteins that signal cells that lead to suppression of inflammation in OA.


Goldring and Otero. Inflammation in Osteoarthritis. Curr Opin Rheumatol. 2011; 23

Xie et al. Biology of platelet-rich plasma and its clinical application in cartilage repair. Arthritis Res Ther. 2014; 16

What is Cupping and why does Michael Phelps swear by it?

What is Cupping?

Cupping is a therapy in which glass jars or cups are suctioned onto the skins surface with negative pressure. Traditionally, cupping has been used in Chinese medicine for 1000s of years to open up meridian pathways to allow Qi to flow through. When Qi flows freely throughout the body one enjoys good physical, mental and emotional wellbeing.

Cupping uses suction and negative pressure to drain excess fluids, stimulate the parasympathetic nervous system (relaxation) and increase blood flow to muscles and skin. It can be used along Meridians and acupuncture points to clear colds and flus and stimulate specific organs, it can also be used along fascial lines across the body to specifically treat fascia and muscles

Why treat fascia? Fascia is connective tissue (has an appearance like a spider web) that covers everything within our bodies – muscles, bone, nerve, organs etc. – it is the 3D glue that holds everything together.  It is what allows our muscles to slide/glide efficiently.  A fascial dysfunction can restrict range of motion, decrease blood flow to an area, and cause pain and toxin build up.

Cupping is different than most manual therapy in that the majority of other techniques use compression, whereas Cupping decompresses (lifts, separates and stretches) tissue to release adhesions and break down existing scar tissue, relax muscle spasms, and decrease trigger point pain. It has also been shown to decrease tissue changes (scar tissue formation) and inflammation following trauma.

What are the marks left by cupping?

The circular marks left behind from a treatment are not bruises and are rarely sensitive to the touch. They are static blood, lymph, cellular debris and toxins being released from deeper tissue layers. Marks can vary in pattern and color and can last anywhere from 3 days to 2 weeks.

So who can benefit from Cupping?

The short answer is anyone, but especially those with joint or muscle pain/tension, headaches, frequent colds or flu that are not getting the relief they need from regular massage therapy. Cupping is historically very effective in treating chronic overuse injuries such as bursitis, tendonitis and other myofascial pain syndromes such as runner’s knee, tennis elbow, and low back pain.