John Post, MD's Blog

Your Medical Help At The Races

2012-02-12T17:21:00.000-05:00

"The road is long, with many a winding turn." The Hollies

The Medical Tent - what would we do without it?

Shorter Warm-Ups It wasn't that long ago, especially for running work outs, that prior to hitting the asphalt, a good bit of stretching, static stretching, was the norm. Also, in races like the time trial day of a multi day stage race, extended time on the trainer would precede the event. I can remember HS Cross Country races where the warm-up/course check was almost the same distance as the race.

I've seen several pieces in the past couple years, including famed running coach Bobby McGee where the old hurdler's stretch and others like it may not only not be necessary but may indeed inhibit progress rather than help. Donna Krupa of the American Physiological Society writes that while the benefits of warming up, increasing muscle temperature, accelerating oxygen uptake, etc. will enhance performance, that researchers at the Human Performance Lab in Calgary, Alberta have found that "less is more." The researchers go on to point out that "If warm-up results in fatigue of an athlete....what impact would it have on (multiple) performances required on the same day?" They imply a negative impact.

I know that we've adopted McGee's techniques and would strongly suggest that you at least look at this 3 minute video from D3 Multisport. http://www.d3multisport.com/video.php?video=Run-warmup-drills . I'm told that McGee has a video out that compliments this and if you've seen it, a comment below would be helpful to other readers.

Unplanned "Finish Line" for some in Kona, 2011

Race Day Medicine

We frequently oversimplify the role of the medical staff into caring for dehydration issues. In point of fact they have to be prepared for almost any medical or trauma situation, both expected and unexpected. This is not always appreciated by the occasional volunteer who's there for the t-shirt. Enter the bike crash victim with half a dozen broken ribs and a pneumothorax (collapsed lung), short of breath and bleeding, and a sense of reality returns. Or the athlete with a closed head injury in need of help - stat! The medical team that works the tent is much like the Emergency Department back home at you local hospital. From heart attacks and hip fractures, to sunburn and over exertion, they are able to provide care. Resolving the episode may not be possible on this level but making an accurate field diagnosis and stabilizing the patient for potential transfer to the local medical center are key. This takes a group of individuals who work at a fast pace, can get a great deal of meaning from a limited amount of information, and even in pressure filled situations where life and death are on the line, maintain their composure, remembering who's the patient.

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Local distance runner Nadia Badr reminds us that it wasn't that long ago that not only the sick or injured were seen in the med tent. So were the impatient (not to be confused with inpatient, like in the hospital.) She has friends, who, upon crossing the finish line in an endurance race, would saunter over to the medical area, not that they were in any particular distress, to have an IV stuck in their arm for instant re hydration. "It's time for my IV," they'd calmly say. This is to be contrasted with the triathlete who, like so many others, has a GI system that's just shut down, will accept no more fluids, but is in desperate need of that IV bag full of fluid and electrolytes simply to maintain blood pressure. Thankfully, screening for med tent entry has changed significantly and those other folks are encouraged to "Keep drinking." (I've been to a few post-race parties where none of us needed to be told to keep drinking! Hooyah!)

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Dislocated Shoulders, Muscle Mass

2012-02-07T09:48:00.002-05:00

“American triathletes work way too hard on easy days ….and way too easyon hard days.” American Olympian RyanBolton

The images below come from a study published in the Physician and Sports Medicine that took detailed measurements of 40 masters athletes between the ages of 40 and 81, and found a surprising lack of age-related muscle loss. These are MRI cross sectional views of the thigh of three different people. The dark shade represents muscle, the light shade fat.

This study contradicts the common observation that muscle mass and strength decline as a function of aging alone. Instead, these declines may signal the effect of chronic disuse rather than muscle aging.

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On the lighter side

When asked if triathlon cut into his family time, a friendnoted that when he started training for Ironman, “The hardest thing wasteaching my wife how to mow the grass!”

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Dislocated Shoulders

Image from Snowsphere removed here!

You know the image. After a particularly vicious tackle, a football player emerges from thepile of humanity cradling his arm like it no longer belongs to him. On the sidelines when the pads are removed,if he’s thin, the deformity is pretty obvious. So is the diagnosis. If thedecision is made to attempt an on-field reduction, the athlete will have limitedchoices for anesthesia. In short, therewon’t be any.

Remember, a dislocated shoulder is talking about the balland socket, the glenohumeral joint, where the term separated shoulder refers tothe joint at the lateral end of the collar bone, the A/C joint. In the athletic world, the cause is frequently a fallor forceful blow to the shoulder….like falling off of a bike or slipping on wetor snowy pavement while running. Therecan be sudden, intense pain with a visible deformity. It can be accompanied by nerve involvement inthe arm, manifested by weakness or numbness in the hand, arm, or shoulder. Occasionally some athletes will report a weakor “dead arm.”

When the ball and socket become dislocated, the ball movesout of the socket. This is most commonlyout the front and “immediate” attention is desired. The first question to answer is whether totry an on-field relocation or proceed with a diagnostic work up first. Occasionally, despite presence of anexperienced operator, conscious sedation or even General Anesthesia isrequired to accomplish this relocation. Post reduction x-rays, immobilization and position areindividualized. Recurrence is morecommon at a young age and in those who are physiologically lax. Even with a rapid replacement of the ball backinto place, it can frequently go on to surgery. Scientist Roger Reynolds reminds us that dislocations are often not simple injuries but are accompanied by a fracture of the humerus, the socket (or both) and careful examination for nerve involvement pays dividends.
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Other joints will dislocate as many of you are aware. Fingers, toes, etc. where the level of injury is not terribly great. But should you dislocate your hip, ankle, mid-foot (Matt Schaub of the Houston Texans) etc., these can be a much more serious issue requiring surgical reconstruction. Achieving full recovery can be challenging.

Reynolds, center, guts it out to the finish line.

Image #2, Google Images, snowsphere

It Hurts, Do I Need An MRI?

2012-02-05T17:18:00.001-05:00

“My psychiatristsent me for an MRI. She thinks I have amagnetic personality.”

So, after putting your bike on the rack on the car after today's ride, you accidentally step back off the curb and roll your ankle. This is pain, big time pain, as you reflexively flop around on the pavement in agony. As the intensity slowly dissipates, and your bike buddies encourage you to get up if you can and get out of the traffic, you find that you can hardly walk on it and wonder now what? If this is serious, everything's going to change from your scheduled track work out tomorrow to the trip to Disney World next week (you hope not that one, the kids have been looking forward to this for weeks.)

Upon arrival home, spousal care helps with elevation and icing. You head to the on line Tri Forum, home of noted medical authority Captain Underpants, or possibly another anonymous poster. (What was their class standing in medical school? Oh that's right, they never went to medical school.) You post your tale of injury, and "Get an MRI," sayeth the good Captain! MRI the others cry! And MRI the foot too, you never know, they add.

Some time later, rroof (a noted Sports Podiatrist from Cincinnati - and not anonymous) says, uh, well maybe you need an examination and a diagnosis first, perhaps an x-ray if indicated. Of course he's right.

This scenario plays out every day on tri forums, in athlete to coach communications, and simple every day life. Those of us in medicine get pushed every day to "take a look" with an MRI when a more appropriate course, perhaps a less aggressive course, is correct. (MRI - nuclear magnetic resonance - produces images of the molecules that make up a substance, especially the soft tissues of the human body. Magnetic resonance imaging is used in medicine to diagnose disorders of body structures that do not show up well on x-rays.*) Noted researcher Jennifer Hodges has found that, "If they're not the ones paying for the examination, they'll be much more likely to request that it be performed."

Typical MRI

Jack Wennberg of Dartmouth’s Center for the EvaluativeClinical Sciences is often quoted as having said: “…up to one-third of the over $2 trillionthat we now spend annually on health care is squandered on unnecessary hospitalizations;unneeded and often redundant tests; unproven treatments; over-priced, cuttingedge drugs; devices no better than the less expensive products they replaced;and end-of-life care that brings neither comfort, care, nor cure.”

It's also interesting to note that this is not just a patient driven phenomenon. In a recent study in the Orthopedic literature, it was found that with physician owned MRI scanners, there was a higher likelihood that a study would be ordered than if the doctor had no financial interest in the unit. Makes you think doesn't it. And these are my peers.

The take home lesson here is that, with MRI examinations that are billed at over $3000 each (thus the consideration of an ankle MRI, and foot MRI as suggested above, would be billed in excess of $6,000.) Some measure of restraint is needed. "Fiscal restraint on the part of both parties," says Hodges. If there's a diagnostic unknown between the doctor and the patient, ask the question, "Would my treatment be changed/enhanced with an MRI? Would we use the information from the scan, positive or negative, to make a decision in my care?" If the answer's no, or perhaps not right now, maybe another treatment entity is appropriate at this time.

Hodges, right, leads post work out stretching - always a good idea.

*American Heritage Science Dictionary

Caffeine 2012

2012-02-01T20:33:00.004-05:00

"I never drink coffee at lunch. I find it keeps me awake for the afternoon." Ronald Reagan

"That's the thing, training is rough. The man who has it the roughest is the man to be most admired. Conversely, he who has had it the easiest is the least praiseworthy."

Helmet For My Pillow, Robert Leckie

If you still train using this philosophy, you might want to re-think your methodology. Maybe, as performance expert Dean Johnson notes, "He who trains the smartest is to be the most admired."

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Caffeine - Your Legal Drug

We've learned a lot about caffeine over the years. Heck, when you consider the caffeine I've consumed so far today without even thinking about it, you'd have to include the coffee I had before breakfast, iced tea with lunch and Diet Coke afterwards. Don't forget my fave, the Hersey's dark chocolate kisses. If perchance I'd had a headache and taken a couple Excedrin, there's more caffeine there than the a.m. coffee. But, you wouldn't find any in the Gatorade I had after working out. The Gatorade web site points out, "Currently, caffeine has no place in Gatorade products. There is no convincing scientific data that shows caffeine can consistently and safely enhance the performance of athletes in a wide variety of situations. Caffeine is a stimulant and many sports medicine professionals have concerns about athletes over-consuming caffeine." As a big company (with a legal division no doubt) you'd expect such a carefully worded statement in that they have no control over who consumes the product or how.

Matt Fitzgerald, author of Iron War and Racing Weight, How To Get Lean For Peak Performance says that, "Caffeine is the most widely used drug in the world. Despite the negative connotations of the word drug, however, caffeine is by and large a benign and even beneficial substance for humans."

It first came to my attention in medical school when David Costill a pioneering member of an early group of physician/runners who wanted to measure, to quantify running, to make it more precise, published early work on the benefits of caffeine to the running population. As a caffeine user, I was asked for a pre and post-race sample of my blood at the finish line in Hawaii to measure the caffeine level a few years back also. If you think about the number of products in our daily lives that are laced with the stuff, it's a sizable list. Think Jolt Cola and Five Hour Energy Drink, think weight loss aids and over the counter pain meds, think chocolate and many ice creams.

OK, so we know it improves performance and your level of alertness but there are a few negatives to keep in mind. As a stimulant it can raise both your heart rate (see blog 3/11/2011) and blood pressure to a degree.  As a slight diuretic, it may increase urination, potentially increasing your risk of dehydration and it's detriment to performance. Know anyone with "the shakes" in the office from that one too many cups of morning coffee? And, don't forget the insomnia for some who have coffee/ tea/etc. after supper.

What is also known is the beneficial effects of this drug are much less in those who are already habitual users. If they double the dose on race morning, it may help a little but the non-consumer will get more of a boost.  I've seen it written that if daily users also want the positive kick from caffeine that we should cut our intake for the week preceding the event and then "pop some" on race morning. A 70 kg athlete would consume about 400 mg 30 -60 minutes before the gun. The effects last around 5 hours and some athletes I know will "re-dose" in T2 of an iron distance race. However, at least once source suggests limiting caffeine to 500 mg per day. Occasionally, the habitual user who suddenly reduces consumption may experience some element of caffeine withdrawal.

Fitzgerald has also noted that pre-exercise caffeine, particularly in the non-user, will diminish post-exercise muscle soreness up to 50%.

So what does Dean Johnson recommend?

     A) decaf the week before and 400 mg as you finish setting up your transition area, or
     B) decaf always except in specific situations, the long drive, expected muscle soreness following a
           planned work out, or pre-race.
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From the Comments in the Death in Triathlon piece last week, Race Director Mark Fromberg notes,

"Caffeine is known to enhance performance, but for those that are sensitive to it, it may cause tachycardia, and gut symptoms that may not be helpful in the swim. Ask yourself if you really need it to race."

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Johnson, center. excelling at local cross country mud race.

Image #2, Google Images

How to Start a Triathlon Swim

2012-01-29T21:03:00.000-05:00

"He don't look like no high school dude!"
Maurice Greene, talking about Alan Webb, then a senior at South Lakes High School in Reston, VA, who, during the Prefontaine Classic in Eugene, OR, ran a 3:53.43 mile to break Jim Ryan's 36 year old national high school record (3:55.3) once thought to be untouchable.

Your future triathlon bike? (The Cervelo display)

My last blog, Death in Triathlon, brought a significant response. (If you haven't had a chance to read it, please do so before you read this as the two are complimentary.) It hit a nerve in a number of readers and I wanted to share some of those thoughts with you as I believe them to be quite pertinent.

They say that experience is the best teacher. And, we can learn from the experiences of others. The point being made that was that if you're going to get into trouble in a race, it would most likely be in the swim and several strategies were discussed in the "forewarned is forearmed" school of thought.

1) You can't arrive at a race sit too early. If body marking, transition set up and warm ups are complete, take the time to just sit. Sit and relax, visualize the upcoming event and the possibilities you've planned for...and maybe some you haven't. When they call your wave, you'll be in total control.

2) Be completely comfortable in your wet suit. I heard from one gal would said that she wore it at home, "Cooking dinner, watching TV, etc." for a little while every night for the couple weeks before the race so she was completely comfortable in it. Like an old comfortable pair of shoes. She also found a flaw in the zipper that if not discovered until race day, would have ruined the event for her. As it was, she got it easily repaired.

3) Know the course cold. Water entry/exit, everything. Walk through it on race morning after you have everything else set up. If you've followed #1, you'll have the time to do it in an unhurried fashion. This would seem obvious to me but potentially not to all.

4) This 4th one came from a physician in Canada who took the time (thanks) to make an extensive blog comment (to Death in Triathlon) that applies to all of us. I'm going to reproduce it below in it's entirety as I feel there's something here for each of us;

Thanks for adding to an important dialogue. As a triathlon physician, a triathlete, and a race director of an open water swim, I feel I can add a few points to this:

From the athletes' perspective, get in the water BEFORE the race starts if possible, to let your wetsuit fill with water and for you to warm it up. That will lessen the shock of the cool water.
Minimize how much you eat in the hour or two before you start swimming. If you need to eat before a race, get up earlier to eat. Digestion and exercise are competing demands that have negative consequences that will stress you especially while swimming.
Caffeine is known to enhance performance, but for those that are sensitive to it, it may cause tachycardia, and gut symptoms that may not be helpful in the swim. Ask yourself if you really need it to race.
Practice swimming in all conditions, including wind and chop and cool water. Athletes will often go home when they see these conditions while training, but you can't do that on race day. Get comfortable swimming in chop.
Practice, if you can, in a safe and friendly environment ( a pool or shallow water) with friends, "combat swims". Most swimmers don't mean to run into you, but the bigger the race, the more inevitable it becomes.
Develop some strategies to avoid swimmers who keep running into you, without getting mad, which only increases your adrenaline further.
Seed yourself appropriately!

For race directors, organizing a race with several smaller waves, each with boat support, are clearly safer than larger ones.
Consider even starting without a loud starting gun (which also stirs up too much adrenalin), instead having everyone's race begin by crossing a timing mat (chip time, as they call it in big marathon races).
Avoid 90 or 180 turns in a swim race if possible. Tight turns cause too much congestion. Try to round the turns where possible.
Give swimmers an opportunity to warm up with some easy swimming.
Make it possible to separate good swimmers from beginners, whether by wave or cap color.

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In short, with just a little pre-race planning, you can ensure both safety as well as success.

.....and take you to your special island. (Billy Joel)

Death in Triathlons, This is Important

2012-01-26T12:28:00.000-05:00

"No man is entirely worthless, he can always serve as a bad example." Brian Oldfield, smoking cigarettes between his shot puts.

I gave my second in a series of talks to the Annual Meeting of Training Bible Coaching this past weekend. One of the topics was The Female Athlete which was presented here late last year as a series of 3 posts. It was also time to review what's known about those who very unfortunately perish in races as well as what's not known in a lecture titled Death in Triathlons.

This is a serious topic that, in my opinion, coaches and athletes should include as part of their pre-season discussions. As the musical group Kingston Trio used to sing, "This could happen to you."

While I won't review the entire lecture, suffice it to say that in the early 2000's there was explosive growth in triathlon accompanied by two unfortunate races, Ironman Utah 2002 and two weeks later the Japanese Strongman, where athlete deaths occurred in both. One outcome of these tragedies was greater alertness of the entire triathlon community, perhaps too high initially where, without a great deal of provocation, the swim portion of several 2003 races was canceled creating duathlons. That said, it made athletes and race directors respectful and cognizant of weather conditions, and for safer races. This is no truer than for the novice racer. In October 2008 Inside Triathlon had an excellent piece noting three deaths the previous July (in three separate races) and 23 deaths in the previous four years, 18 of which occurred in the swim. Even with expert autopsies, the exact causes of these deaths were not always apparent. This can be true on land as well. Consider the unfortunate death of marathoner Ryan Shea in the Olympic trials in Central Park in 2008 who passed away at the 5.5 mile mark of the race. Ryan was known to have had an "enlarged heart" (but not the so-called hypertrophic cardiomyopathy that sadly claims the lives a few young athletes each year). This diagnosis was made many years before his demise, prior in fact to him winning 11 HS State titles, the NCAA 10,000 meter championship, etc. According to the NY Times, the Medical Examiner felt Ryan's death was due to an irregular heartbeat.

Back to triathlon swimming. Fast forward to a Washington Post article by David Brown 11/14/2011, "Deaths in triathlons may not be so mysterious; panic attacks may be to blame," who put forth the idea that panic attacks and anxiety may be playing a bigger role than previously credited. In my opinion, this is very real. While experience is an excellent teacher, consider the following: how many times per year do we wear wet suits? Are they a bit constricting and perhaps claustrophobia-inducing? Are our swimming mechanics different in a wet suit in the open water than in a Speedo in the pool? Although many of us are pretty good pool swimmers, the difference between controlled lap lanes at 84 degrees and the mayhem of a group start in sub 70 water is substantial. Can everyone maintain control when they are being crawled over, kicked, goggles knocked askew, etc. I think at least a part of our solution may lie here.

My recommendation is to think about all this pre-race and have options. If you are coached, have the discussion with your coach.

Try to swim at least the beginning of the course, in your wet suit, the day before the event so that at least one unknown is eliminated. It can be a real confidence builder.
If there's any doubt in your mind, when the gun goes off, wait 10 seconds for your own piece of the ocean or lake. You'll get cleaner, less turbulent water anyway and make up some of the difference.
Swim a little wide around the buoys to avoid congestion.
If you get at all anxious, flip over on your back, take some time and deep breaths until you feel like you're in control again. And if you don't regain that sense of command, screw it!! Side stroke back to the start, to dry land, and save your efforts for another day.
Most importantly, if the conditions look like they exceed your level of comfort, have the fortitude, as Betty Ford taught us, to "Just Say No," and save your efforts for another day. I was in a race in Virginia Beach a few years ago which included a 1K ocean swim parallel to the shore. The waves were pretty big that day and as my friend and I walked to the race start, we followed three (non-wet suited) young ladies obviously new to the sport. As they approached the swim start line, they looked at the somewhat angry ocean, at each other, and back at the ocean - and left! They never started the race as they agreed the conditions were beyond their skill level. It's OK for you to do the same. It's called good head work.

Taped to the aero bars of one racer's bike in Kona - nice!

Photo #1 from Tri Madness

Winter Running Rules

2012-01-22T21:11:00.000-05:00

"But it's a five o'clock world when the whistle blows, no one owns a piece of my time." The Vogues

Thinking about going for a run after work? Me too. Many of the posts on this blog are pointed toward safety. Visible clothing and possibly a strobe in these shortened daylight hours, being especially prepared if you have Raynaud's, etc. On 12/18/2011 I did a piece titled "Frostbite Avoidance, Dressing for Winter Training" which serves as a good base for this topic if you haven't read it yet.

Prior to your run, practice dynamic not static stretching techniques like light skips, bounding, high knees, butt kicks and back pedals. Save the static stretch for after you've completed your run.

Note importance of core exercises (and sledding) in the snow.

Dress properly....not too much and not too little. Your body will warm up 10 - 15 degrees above the air temperature. Embrace, don't fight whatever weather conditions you face. It was 20 degrees, in the dark, when we started our work out this morning with 44 folks, and shedding clothing became the rule of the day.
Deliberately start with a very slow jog or fast walk for your first half mile and always make your first mile the slowest of your run. Your last half mile should also be run at a slower pace as this helps with your post run recovery.
Keep your stride length short and remember the suggested pacing of 30 Rt. foot strikes per 20 seconds (or 22/15 secs.)
Maintain a "conversational pace," aerobic heart rate. If you can hear yourself breathing, you're probably running too fast.
Follow your RPE, rate of perceived exertion by maintaining the same effort, not the same pace, through out the varying terrain of your work out. Obviously this is particularly important running up hill.
You longest run of the week should not be greater than the sum of the other runs.
Take it easy on the down hills, shorter stride length is the key.
Say out of the "gutter" (side of the road) by trying to maintain balanced stride lengths.
Try to get something nutritional into your system within 20-30 minutes of completing your run as recommended by Triathlete Magazine author Matt Fitzgerald in his book Racing Weight. It could be a banana, Clif-bar type product and a sports energy drink or chocolate milk. Yes, chocolate milk.
Make sure you record the stats of the run in your journal including what works and what's not working.
Drink at least 60 ounces of hydrating fluids/ day....sodas don't count.
Make sit ups and push ups, which work on core strength, a part of your daily routine and use Pilates and Yoga as your "cross training."
Get adequate sleep - I know this is hard for most! The more you exercise the more rest you will need.
Listen to your body's communication signals. Feeling fatigued? Then back off. Have a new ache or pain (knee, shin, hip, ankle, Achilles?) Then talk it out with your coach ASAP.

But when you're heading out for that five o'clock run remember that upon hearing Joe Jacobi of the Washington Redskins say: "I'd run over my own mother to win the Super Bowl," Matt Millen of the Raiders said, "To win the Super Bowl, I'd run over Joe's mom, too."

Some say that winter running is the best there is. If you follow these simple rules, I'm sure you'll agree.

Thanks to Mark Lorenzoni, author of the above, and his desire to "spread the word."

Thanks to NIkki of SEAL Team PT for photo #2.

Distance Per Stroke, Decreasing Shoulder Stress, Increasing Speed

2012-01-15T19:49:00.000-05:00

"And I'll take every moment and live it out loud...."
Time of My Life, David Cook

Surf boards form a channel for the final 2.4 mile swimmer - who did NOT make the cut off!

January, a perfect time to become a better swimmer.

Although we aim to swim well, within our best skill levels, our race day abilities rest on successful training and injury avoidance. Few triathletes label the swim as their strong suit (I am one of them) but if a tool exists that would both increase their speed in the water while diminishing their energy expended, it might be worth examining. Olympic level swimmers like Michael Phelps, Dara Torres and Natalie Coughlin (http://www.youtube.com/watch?v=-iA6fyGmQf8) practice techniques to decrease their stroke count per 25 yards, in other words the distance they get from each stroke. If you choose to adopt this technique, you'll see faster times, a more efficient stroke, and energy saved for the latter parts of the triathlon. (A couple of years ago I was sitting in the stands of the University pool watching a woman do her swim work out. For some reason, from my perspective she looked awkward, ungainly and I remember not thinking much of her abilities - until I counted her strokes. 14 strokes/25 yards and then her times, just over a minute/100 yards continuously. Obviously, I changed my mind about her right quickly.)

Famed Swim Coach Emmet Hines, in a 1993 article put it this way, "Assume you are 6 ft. tall and have approximately a 5 ft. effective wing span measured wrist to wrist. Swimming or pulling with 100% stroke distance efficiency, you should be able to travel approximately 5 ft. with each freestyle arm stroke (10 ft. for each right-left stroke cycle). In a 25 yd. pool you push off from the wall and begin your first arm stroke at approximately the backstroke flags, leaving 20 yds. (or 60 feet) to swim. If you start counting each hand hit as you stroke down the lane at 100% efficiency you should contact the far wall after 12 strokes (or 6 stroke cycles). If you are 5 ft. tall this would work out to more like 14 strokes per length (6'6" about 11 strokes, 5'6" about 13 strokes*)." It's pretty unlikely that any of us would achieve a stroke rate of 12, but if we can use this example to decrease our current rate by 2-4 strokes, we win!

Most athletes understand the principles of increased distance per stroke, DPS, but few have the patience to actually add it to their repertoire and reap it's benefits. It's like the NBA where Rick Barry notes his ability to increase the foul shooting percentages of players by teaching them the under handed shot but few if any take him up on the offer. I suppose they're satisfied with shooting 60% from the charity stripe. To adopt any new stroke change requires motivation and patience, some times in short supply with type "A" triathletes.

To start the learning process, swim 25 yards in a pool and count the number of strokes you take with your right hand. Double it. This is your stroke count. I'd suggest you try this 6 or 8 times until you get what you think is an accurate assessment of your current stroke count. Many suggest doing this at warm up pace and then again at "race pace."
Then on the next 25, take one less stroke by working on a lowered head position, neutral body, and concentrating on just a little more efficiency with the kick. You won't descend from 23 stokes per lap to 15 the first day but you can go to 21 or 22. You are not trying for speed here, only stroke count.

Warming up before race day, getting used to the salty water taste.

Maintaining your DPS, try a set of 6 X 50 on 2:00 or 2:15, whatever it takes to be rested, concentrating on stroke count. Be prepared to glide between strokes. It's easy to practice during warm up drills. This is all predicated on the understanding that each of us has some happy medium, a stroke rate below which we actually slow down. This is only January so if you can do a portion of every swim work out between now and the summer race season working on your DPS, imagine how much you might improve. Go for it!

*USMS News, 4/1/1993

Rotator Cuff Tears

2012-01-08T20:31:00.000-05:00

"What about now, what about today?" Daughtry

Not all triathletes succeed

There can be stumbling blocks in our path to success. One of these can be a rotator cuff tear. It's quite frequently the cause of one's shoulder pain although there's a long list of etiologies here that would include the joint, any of the muscles or tendons which surround it, the neck and nerves which emanate from it, the heart or gall bladder, infection and tumor to name a few. Frequently we'll see someone grasp their painful shoulder noting the presence of "rheumatism." They couldn't be further from the truth. And, we're not talking about a separated shoulder here (you can read about that in the 9/11/2011 blog). Assuming these other potentials have been ruled out by your physician, and the diagnosis of rotator cuff disease is made, where do you go?

First, the basics - the rotator cuff is made up of of four of the smaller muscles in the shoulder and it serves many functions. Primarily, the cuff musculature holds the humeral head in the socket so that the larger muscles like the deltoid can provide the mechanical force for work.

This diagram shows the cuff made up of supraspinatus, infraspinatus, subscapularis and teres minor muscles. Tears usually occur where the cuff inserts into the upper humerus and although some occur acutely(motor vehicle accident, fall which possibly dislocates the shoulder too), the majority occur over time, slowly, beginning with fraying of the upper surface of the cuff. We often divide tears in to partial or full thickness. In a full thickness tear, there's actually a hole in it. And, as a degenerative process, there may be a tear on the opposite side too, even if it doesn't hurt. Symptoms classically include:

night time pain
a sense of weakness with use
pain with lifting or raising the arm
crepitus, cracking, a noisy shoulder

Initially you might only feel mild pain with a long swim or putting your bike up on a rack but over time it seems to hurt with more minor actions and at night. When you see your physician, he/she takes a thorough history (to exclude any of the other causes of shoulder pain as listed above) and performs a careful exam, occasionally including x-rays. If a cuff tear is suspected an MRI or ultrasound may assist making the correct diagnosis. Please read this as not everyone needs an expensive study like an MRI.

If a tear is diagnosed, it doesn't necessarily mean surgery. About half of the time, non-surgical means such as rest, activity modifications, physical therapy or a home strengthening plan, even a cortisone injection or two (see blog 2/5/2011 for injection details) may be all that's needed. This is especially true for the lower demand (read non triathlete) patient but it does little to preserve or increase the lost strength of the arm. And, a portion of these tears that are not fixed will increase with time. (Now he's talking about what I need to know.)

The Orthopedic Surgeon can recommend that you have your tear fixed if it's a large tear at initial diagnosis, the symptoms have been present for 6 - 12 months, you have weakness or function loss, etc. The procedure is usually done as an outpatient under anesthesia, and can sometimes be completed arthroscopically with no formal incision other than the small punctures to get the scope and related equipment into the joint. A somewhat more difficult repair can be done thru a "mini-open" process where a 3 cm incision over the side of the shoulder is all that's needed. Much of the operation is still done with a scope.

Lastly, if you have a very large tear, you may still require formal open surgery to re-attach the tendon to the bone. These procedures take approximately two hours and you'll be placed in a sling or some type of brace to support the arm post op. The immediate goal is pain control for the first 3 - 5 days post op using narcotics, ice therapy and even anti-inflammatory drugs. Sleeping can be a real challenge for the first week or more - it's hard to lay down with the sling on - and sleeping in a recliner can be more effective.

Your return of motion and strength will be guided by your physical therapist but plan on 4 - 6 months to fully recover, longer in overhead throwing athletes, and return to sport. Remember, each person and each tear is individualized so it would be unwise to compare your situation to that of one of your training partners. Good luck!

Images 2 and 3, American Academy of Orthopedic Surgeons

Knee Pain, The A, B, C's

2012-01-01T13:25:00.000-05:00

"As we live, a life of ease, every one of us, has all we need, sky of blue, sea of green...." The Beatles, Yellow Submarine

It's been reported that by 2013, one in six visits to the doctor will be for knee pain. Perhaps you've already been one of them. I suggest this because one of my most frequent questions will be from an athlete who's failed conservative care and is preparing for an operation. Hardly a week goes without correspondence coming from someone preparing for an arthroscopy, microfracture, joint replacement, etc. and they all want to know about the probability of being able to train and race afterwards. "When can I run?" I submitted a piece to Inside Triathlon this week discussing the events surrounding surgery that will hopefully benefit the Tri community.

Knee Pain

So let's say you have knee pain. Without going through every possibility, what are the 10 most frequent causes of pain in the triathletes knee?

Arthritis Realize it or not, wear and tear on the joint is one of the most common sources of pain. This can be cartilage deterioration on the back of the knee cap, so called CMP or chondromalacia patella, or in those who've had a portion of a meniscus removed in the past who are experiencing a change in load sharing in that part of the knee. The third group would be our more "Seasoned triathletes."*

Bursitis Think of bursitis as a (hopefully) transient problem with the joint. Directly in the front of knee, the pre-patellar bursa when inflamed is called house maid's knee and commonly seen by those who spend a good deal of time kneeling. Pain over the upper, inner reaches of the tibia can come from the pes anserine bursa, the insertion of the hamstring tendons which flex and rotate the joint.

Cartilage Tears The knee cartilage, or meniscus, one on the inside (medial) and one on the outside (lateral) of knee are formed of so-called fibrocartilage. They assist in stabilization of the joint as well as the transfer of stress across the joint. The mechanism of injury frequently involves some type of twisting or rotation of the joint, not lots of pedaling or running. The joint can swell, crack or pop, and even buckle or give way. Only occasionally will they heal by themselves.

Iliotibial Band Friction Syndrome A very common problem, particularly in runners. The athlete complains of pain on the outside of the knee, above the joint, as a wide band of tissue travels across a bony prominence. It's frequently worse with exercise and worse with those who increase their training at too rapid a rate.

Baker's Cyst These are a sense of fullness or swelling directly over the back of the knee joint. Some can be as large as an orange but most are less impressive. Although they can occur spontaneously, the most common etiology is secondary to some other problem coming from inside the joint such as a meniscus tear, arthritis, etc.

Patellar Tendinitis Just below the knee cap lies the large patellar tendon. Another of the overuse injuries is patellar tendinitis with symptomatic pain here. A sub category is called Jumper's Knee. Just as the Achilles is subject to micro tearing, so too can this tendon tear in this manner. Going down hill or down stairs can be quite painful as can pressing on the tendon. I've seen some produce a cracking or creaking noise which can be very worrisome to the owner. Only very infrequently will they rupture.

Ligament Tear Three of the more common major ligament tears include the ACL, anterior cruciate ligament, MCL, medial collateral ligament (think Tom Brady or Adrian Peterson - they tore both) and the PCL, the posterior cruciate ligament. These violent tears would result from a major twisting or wrenching of the knee. Although the two examples I listed here were NFL players, the most common cause is simply the athlete who slips and twists the limb. Really, all by him or herself! These can be not only season-ending injuries but, in some cases, career-ending! They're a big deal.

Dislocation of the Knee Cap Unless there's been prior joint surgery, the patella, when it dislocates, does so laterally. When the leg is straightened back out, the knee cap will spontaneously relocate but the probability of recurrence is considerable. Also, it's not uncommon when the dislocated knee cap pops back in for damage to occur to the back of it. More common than an actual dislocation is a joint in which the knee cap "subluxes" or partially dislocates. It can be malaligned as well.

Osteochondritis Dissecans OCD is seen usually in the adolescent population and is an incomplete fusion of a small portion of the bone. Some can be asymptomatic.

Osgood Schlatter Another issue seen in the growing knee which presents with pain over the front of the tibia and enlarging bony attachment of patellar tendon into the tibia. It's usually a self limited procedure.

We've talked before many times about when to seek help from your care giver. If the pain occurs at rest or wakes you from sleep, if it makes you limp altering your form possibly setting you up for yet another problem, calf or joint swelling, or anything that's prolonged more than a few days or worries you.

I wish you the Happiest of 2012 and a hopefully successful and injury free season.

*Thanks to Bob Vigorito, race director of Eagleman Ironman 70.3. This is the term he uses to describe the over 50 wave as he escorts them into the water to start the event. Nice man.

You Should/Shouldn't Become a Barefoot Runner

2011-12-27T19:47:00.000-05:00

"It was somewhere in a fairy tale....."

Taxi, Harry Chapin

Everyone is looking for that magic bullet, the one that will make them just a little faster on the bike, get them out of the water just a bit quicker or give them just a tad more stamina on the run. I'm hoping that all of these searches are legal and don't involve performance enhancing drugs as the long term downside far exceeds the short term benefit. (But people will always cheat, unfortunately. This year in Kona one entrant "lost" his chip on the run and cut the course by 4 miles by not going down into the energy lab. A few years ago one biker carried two timing chips, his and a friends, over the timing mat at the Hawi 56 mile bike turn around . The so called Rosie Ruiz look-a-likes of triathlon.
(She was the woman who crossed the finish line as the winning female in the 1980 Boston Marathon but looked "remarkably sweat-free and relaxed as she climbed the podium to accept the winner's wreath" by the New York Times.)

So, in addition to training harder or differently, we look in other directions for not-so-free speed, and is the barefoot running movement the one for you? (In this piece, the term barefoot refers to both absolutely shoeless and to the glove-type running apparel but not to the array of minimalist running shoes which have their place and can work for some types of runners.)

Barefoot? Well, it depends. First, if you've read this blog before, you know that one of the primary goals here is to reduce the injury rate in training and racing. You've also seen that the published injury rate is over 50% in everyday runners and approaches 90% in those training for a marathon each year! Barefoot running is said to diminish this stat in a number of ways from strengthening the foot musculature and by making the runner a forefoot or mid foot striker as opposed to the heel striker which so many of us are. In other words, the change in foot wear is said to lead to a change in running mechanics and the shoe may get some but not all of the credit. There is also frequently a cadence change with this. The thought is that increasing one's stride rate decreases the stress the limb bears as does forefoot or mid foot striking. In short, the lower limb becomes a more efficient shock absorber in this manner than that of the heel striker. If you were to watch the stride rate of elite runners such as the Kenyans, you'd see that they take in excess of 180 strides per minute, 90 per leg/minute. This is easy for you to determine for yourself by counting the number of times the racer strikes the ground with his/her right foot in 20 seconds. Then, if you don't already know your own rate, count it out on your next run to see where you stand. Is there room for improvement?

These glove-like shoes like the Vibram 5 fingers have not been on the market long enough to give an accurate picture as to their long term effects, both positive and negative. And, transitioning to them is not done over night but rather over a period of months rather than days. Anything more quickly and the potential rate of injury could be higher rather than lower. Joe Friel in the Triathletes Training Bible suggests that if contemplating this change from heel striker that you "Save this change for the next Prep period of the training year when run durations are short, and at first run only on soft surfaces such as grass, dirt or a track, allowing plenty of time for recovery between runs."

Runbare.com suggests that when making the barefoot transition that "...it takes time. If you do too much before they’re ready, you risk tendonitis, muscle tears, strained ligaments, or stress fractures. To avoid all of this, you need to go slow, and consider tiny distances to begin with." Understand they have a bias and want you to buy their book. The other side of that coin might be the assistant manger of one of our local running shoe stores equipped with years of experience dealing with all types of running shoes and runner's problems states "I NEVER recommend Vibrams and try to dissuade everyone who walks in the store asking for them." This is not true of other minimalist footwear. Or, David Westerdahl, MD, an Orthopedist of the Cleveland Clinic who feels that "One final thing to consider is by the time many triathletes exit T2, they are running on fatigued legs, trying to survive to get to the finish. In my opinion, unless you've done extensive training to adapt your form and condition your feet to the changes of barefoot running, the final leg is not the best time to run barefoot."

I'll leave you with a few quotes from the November 2011 Barefoot Running Round-table in London called "Natural Running - advantages and disadvantages."

1) Prof Benno Nigg, a world leading biomechanist, asks his students this question in a final exam: "Does barefoot running prevent injuries?", and the only answer he accepts for a good grade is "I don't know because we don't know."

2) Dr. Ross Tucker, Science of Sport, noted that "barefoot running is, at it's worst, a good training modality that may have benefit for running performance." But, "There may be people who simply cannot adapt to barefoot running....shoes may be the only thing enabling them to run."

"People who have run in shoes for many years do NOT run barefoot the same way as people who have been barefoot for a long period."

Conclusion - "we need future research to help us fill in the spaces between what is known and what needs to be known."
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***If you as the athlete are willing to virtually start over with your running in your transition to barefoot running, then you have a good chance of making it work for you. But, if you only have a couple of months to effect change, barefoot running may lead to further injury and may not be your best choice.

Image #2, Google Images, New York Times

Frostbite Avoidance, Dressing for Winter Training

2011-12-18T21:45:00.000-05:00

"With the right gear you can put a man on the moon. There's no such thing as bad weather, just bad gear."
John McGuire, Former Navy SEAL

If this is your first winter training outdoors this post can make a big difference in your comfort and safety level. Although it may not seem like it, the right choice of clothing and equipment can make the Winter run or bike every bit as enjoyable as Spring. In previous posts I've discussed the importance of being seen by traffic, fresh batteries in your bike rear strobes, running reflector vest or belt light, etc.

Frostbite is entirely avoidable with just a simple understanding of what it is and measures to take to reduce the possibility of suffering it. Blood has to travel a long way from the heart to get to the hands, feet, nose, ears, etc. These locations at at the greatest risk for suffering an injury due to cold. When the exterior temperature is below freezing, with inadequate protection, the exposed (or improperly protected skin can literally freeze.

With Winter training comes the need for covering body parts balanced with maintaining mobility. Couple this with the reflex constriction of these peripheral blood vessels shunting blood away from the fingers and toes to the muscles and organ systems. Frostbite begins to occur when these digits actually begin to freeze and then we see the skin die due to lack of oxygen from the loss of blood supply.

Frostbite is frequently divided into two groups, superficial and deep. On the superficial side, the athlete notices itching, a burning or tingling feeling, and likely even numbness. For those suffering from deep frostbite all sensation is lost, the skin turns a whitish purple color and blisters form.

With rewarming, pain is the hallmark of both as the flow of blood is returned to the area. This pain can sometimes be considerable. It's said that this progresses to a deep aching type pain which can last for many days. Initially, oftentimes the patient doesn't have the appearance of one with a significant problem but as time passes, the full extent of the damage can be realized.

Not all cases of cold exposure damage are as significant as the above, some merely experience frost nip or chilblains. Any symptoms such as tingling or numbness resolve (but not without some pain) when the tissue is rewarmed. I'm certain that many of you who live and train in the cold have experienced this. I know I have. Lastly, hypothermia frequently accompanies these problems, and if severe is more important to address than the skin.

Prevention is, of course, the most desirable pathway. As athletes who train in sub freezing conditions, knowing that this is a risk can be a big help. I read that frostbite sufferers share the "Unwillingness or inability of the person to remove himself or herself from the threat." In short, dress for the expected weather conditions! You can be both comfortable and visible throughout the winter months. If you simply check the weather forecast as you plan your workout the night before, and then the morning temperature before you head out the door (an inexpensive thermometer outside your bedroom or bathroom window does the trick as it can be considerably cooler at your house than where the TV station gets their reading.)

Then, think of your core dressing in layers with a goal of staying dry by not using cotton next to the skin as it absorbs moisture (sweat). Any of the light weight technical poly fabrics that wick away moisture will do nicely. Then a layer or two of a long sleeve technical shirt under a wind resistant jacket, usually not Goretex as it can be too hot, and you're set. Know that your first moments outside will be a little chilly but once you crank it up you'll be toasty. For your hands, think wind resistant, possibly mittens. Some will wear gloves under, some - like those with Raynauds (see previous blog posts) - will use chemical hand (and feet) warmers but this will become automatic with a little experience. As for your feet, running shoes with a skosh more room and Smartwool socks are great. If you're considering going out in slippery conditions like fresh snow, think about a pair of inexpensive Yaktrax which act like mini spikes. Lastly, we can lose a lot of heat through our heads. You can experiment with a fleece cap, or simply a generous head band over the ears to see what you require. With just a little practice, you'll see what works for you at particular temps, and be able to safely and comfortably train outdoors all winter, every winter.

Bike Hygiene, Puhleeze! (And How To Pee On a Moving Bike)

2011-12-14T11:07:00.000-05:00

"Life is a highway. I want to ride it all night long." Rascal Flatts

Each of us thinks differently about that two wheeled machine we spend so much time on in training. We spend hours making sure that it's in peak condition at the start of a race so we don't have a bike related mechanical issue. It's our platform for our nutrition plan. It can also be the site of emptying one's bladder, something learned the hard way (following too closely) in draft legal races. I present to you a few before and after images to show how some spend their 112 miles and whether you think their nutrition plan a success or not.

Before

After

YUK!!

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If you're just a little tired of Christmas music, you'll really enjoy this a Capella men's group from a few years ago. They're simply remarkable. http://www.youtube.com/watch?v=2Fe11OlMiz8

Peeing on a moving bike.

When I was standing in the registration line of an Iron distance race a few years ago, I saw a man about my age and we began talking race strategy in this very slow moving line. When I asked if he thought he'd need to stop to pee over the 112 miles, he exclaimed, "STOP!? Why would I do that?" He then went through the details of how to get this bodily function accomplished. When you're on a downhill, stop pedaling and put most all of your weight on the pedals. Then relax, and just go. And according to him, just a little "Swish, swish, swish with your water bottle" to the crotch of your bike shorts, and you were done. Hmm, sounds simple enough, how could it possibly go wrong?

I'd watched videos of the riders in the Tour de France coast to the back of the peleton for a "comfort break" per Paul Scherwin, undo their bike shorts and just hose down the curb, the trees, race fans, cars, whatever happened to be there as the group was going 30 mph. It didn't seem like something I was interested in but this new method seemed more civilized and if things worked out right you could still PR on the bike. Cool! I tried it on race day and it worked great. In fact, I may have been a little over hydrated as I was able to "practice" the technique a couple times.

One suggestion. Wash out your bike shorts immediately following the race. I did not. In fact, I packed my bike to run bag just as I had picked it up from T2 into my suitcase. And to make things worse, when I got back home, I just took all the tri gear and threw it outside on the screened-in back porch to get to it another day. Well, we all procrastinate sometimes. After about two weeks, my spouse decided to "help" me with cleaning up my stuff. Bad decision. When she opened this particular bag, in the words of Gilda Radner as Roseanne Roseannadanna, 'I thought I was gonna die!" Apparently, it let out the aroma of ten dead skunks, or worse! Maybe eleven! Her only possible course of action (she said) was to throw it all in the trash, "Life is too short, John," which I heard about four times during supper. I decided that the safest course was to not complain about the loss of bike clothing and merely say thanks. I wash out the "new" bike shorts now.

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I was asked by the American Academy of Orthopedic Surgeons to pass the below along.

Legislative Alert – New Good Samaritan Protection Bill Introduced

Protect Patients Now needs your help in support of an important, bi-partisan bill introduced last week in the US House of Representatives. Contact your Congressman today to ask him to cosponsor H.R. 3586, the Good Samaritan Health Professionals Act, to ensure patients have access to vital, on-site medical services in the wake of a natural or man-made disaster.

As the nation witnessed during Hurricane Katrina and other recent disasters, there was a critical shortage of medical volunteers on the ground to assist those in need. Due to inconsistencies in federal and state laws, these volunteer health care professionals have been turned away or limited in the scope of their assistance because of the threat of medical liability lawsuits.

The Good Samaritan Health Professionals Act would help protect medical volunteers from lawsuits during a large-scale disaster, and ensure that vital health care services are available to disaster victims.

Image #9, Google images

The Female Athlete Part 3, The Pregnant Athlete

2011-12-11T18:28:00.000-05:00

"You got to do what you can, and let Mother Nature do the rest."

A great look in the 2011 Kona Underpants Run.

The Pregnant Athlete

The most important aspect of athletic participation duringpregnancy is the level of physical fitness prior to conception. The greatest concerns for activity duringpregnancy include:

Effect of exercise on blood flow to the fetus.
Effects of exercise on the weight of the fetus.

The benefits of exercise during pregnancy include weightcontrol, improved muscle tone, self-esteem, decreased incidence of varicosities,decreased incidence of back pain and decreased incidence of sleepdisturbance. The following is a summaryof the American College of Obstetrics and Gynecologyguidelines for exercise and pregnancy.

Direct Contraindications toExercise During Pregnancy

Pregnancy induced hypertension
Preterm rupture of membranes
Preterm labor during the prior orcurrent pregnancy
Incompetent cervix/cerclage
Persistent second or thirdtrimester bleeding
Intrauterine growth retardation

Recommendations About Exercise DuringPregnancy

1. Duringpregnancy, women can continue to exercise and derive health benefits even frommild-to-moderate exercise routines. Regular exercise is preferable to intermittent activity.

2. Womenshould avoid exercise in the supine position after the first trimester. Prolonged periods of motionless standingshould also be avoided.

3. Womenshould be aware of the decreased oxygen available for aerobic exercise duringpregnancy. They should be encouraged tomodify the intensity of their exercise according to maternal symptoms. They should stop exercising when fatigued andnot exercise to exhaustion. Weightbearing exercises may under some circumstances be continued atintensities similar to those prior to pregnancy throughout pregnancy. Non-weightbearing exercises such as cyclingor swimming will minimize the risk of injury and facilitate the continuation ofexercise during pregnancy.

4. Morphologicchanges in pregnancy should serve as a relative contraindication to types ofexercise in which loss of balance could be detrimental to maternal or fetalwell-being. Any type of exerciseinvolving the potential for even mild abdominal trauma should be avoided.

5. Pregnancyrequires an additional 300 kcal/d to maintain metabolic homeostasis. Thus, women who exercise during pregnancyshould ensure an adequate diet.

6. Pregnantwomen who exercise in the first trimester should augment heat dissipation byensuring adequate hydration, appropriate clothing and optimal environmentalsurroundings during exercise.

7. Manyof the changes induced by pregnancy persist for 4-6 weeks post-partum soexercise routines should be resumed gradually based on a woman’s physicalcapability.

In conclusion, the need for the physician to understand theunique aspects in treating female athletes is paramount. Adding these insights to primary care willonly improve diagnostic and treatment efficiency. Certainly further research is needed tobetter understand increased knee injury incidence in females compared tomales. Also the observant eye for diagnosingthe female athlete triad is the first step to initiating early and moresuccessful treatment in a syndrome where the patient and those around her areprone to avoidance and denial. As aphysician, guiding exercise and athletic activity through all ages and evenduring pregnancy of your female patients will be rewarding to your practice andempowering to your patients.

Off Season Tri Alternative, SEAL Physical Training

2011-12-07T20:26:00.000-05:00

"And now, for something completely different." Monty Python

Many sources talk about variety, change of pace, do something other than swim-bike-run at this time of year and I agree. This is an article I wrote for another publication that I've modified for this audience.

Fellowship among triathletes is not often discussed in the realm of intervals and Power Taps but for many it's an important part of their tri experience whether they realize it or not. I wholly agree. Triathlon can be as important to one's mental health as physical fitness. Starting one's Monday work week work at the pool, discussing the events of your lane mate's weekend, and arriving at the work place with wet hair and a smile on your face feeling eager and refreshed make you a better employee.
I'm convinced.

How I Know Today Is My 64^thBirthday?

“They won’t talk toyou unless you’re in push-up position.” It was with these words of encouragement that I joined my son Ben atSEAL Team Physical Training a few months ago. STPT was started in Richmond, VA several years back by a former NavySEAL who had ideas on making those around him stronger and fitter. And he needed a job. It worked well enough that there are brancheshere in Charlottesville, Richmond, Washington, DC, and they’re in the processof setting up in other metropolitan areas. We meet every weekday morning at6:15, come rain, come shine, come whatever, and heaven forbid someone’slate. It becomes an “opportunity to getstronger.” Thegroup pays for individual shortcomings - we get to do push-ups. Only 20 or so if the instructor is in achipper mood, 30 or more if not. Usually it's not. Then wego for a warm up run. Often times it’sthe old indian file which I hadn’tdone since high school. And that was along time ago. Following our run, the group could do bear crawls, sit-ups, morepush-ups, pull-ups, inclined sit-ups on the side of a nearby hill, crab soccertag, did I mention more push-ups?, sprints, etc. At the end of the hour, the group of 40 – 50is a bit tired, has had a great work out, and is generally smiling and chattingactively. In fact, their first questionis commonly, “Where is the work out tomorrow?” We never do the same work outtwice. And at approximately two month intervals we do the Navy PhysicalStrength Test to get an accurate idea of where we stand. What’s really encouraging in this self-pacedwork out is there are all sizes and shapes of participants from those who run 7minute miles to some who started the class being unable to do even a single situp. But on the days we do the PST,virtually everyone can see personal improvement. A sincere effort is made to recognize thisimprovement in each individual, identifying them by name and accomplishment. And the gent who couldn’t do a sit up a fewmonths ago? He managed 19 of them at arecent PST. A feat for which he received tremendous support and positivefeedback from the group!

Fellowship amongadults is not often easy. Sure, when you’re part of an athletic team or large company there’s always a softball game or touch football on Sunday afternoon. Unless the Packers are playing of course andthen it’s a different kind of fellowship. But, outside the service or business work place, friendship is notguaranteed. In fact, it can be quite asurprise to those used to the camaraderie of the office lounge. I remember quite vividly the comments of afriend who was quite used to his superior military position carrying over to hiscommunity life, easy recognition and great service at the establishments intown. But when he retired and moved to anew community, he was most dismayed to report that at the barber shop, “I wasjust next retiree in line.”

We come froma culture that rewards fitness. Ourchosen avocation has done likewise. Is there any reason that we couldn’t continue to lead by example? Or, should we – as has happened to many whoshow up a little late for our high school class reunion dinner parties – walk in to a groupof classmates and think, “I must be in the wrong place, these are all old people?”

As aphysician, I see people from all walks of life in my office, many who’vediscarded any sense of commitment to exercise. I’d say we started off our careers with a higher sense of fitness thanmost. I’d also vote that we make theeffort to stay that way.

Here incentral Virginia, we’re surrounded by parks with lakes. Boats play an important part of teachingteamwork, an essential in STPT. Theinflatable Zodiacs and kayaks also add to the variety. The Zodiac races are something to behold. Not pretty, but exciting. Splashing water, cheering voices, boatsheading in a variety of differentdirections, many not close to the intended course, and the occasional manoverboard drill when someone misses astroke. Since many of the work outsbegin before dawn we’re on the water in the dark. It’s quite a challenge to jump overboard,dressed, with a life preserver on and swim under the craft, hand over hand, feeling the ribs on the bottom of the boat, when it’s pitch black. But, when you do bob up on the opposite side,it gives you a real sense of accomplishment. As you’d expect, this task is more difficult for some than others but ifyou begin to fail, in this or any other aspect of STPT there’s always someonenearby to help you out.

While floating next to the boat once, I madethe mistake of retying one of my running shoes, totally by feel. When this “infraction” was noticed, I wasasked by Instructor McGuire, only half in jest, “What’s the matter? Didn’t Mommy and Daddy teach you how to tieyour shoes right?” (I always double knotthem now.)

So how did I know itwas my 64^th birthday? Well,we started off today’s workout with 64 push ups and one to Beat Army of course. Little did these people, most in their 20’sand 30’s know what was coming. They’requite used to birthday push ups – for people their own age – but as we passed40…and then 50, from the back of the crowd came a loud, “So how old are youanyway?” That voice did 14 more push ups,and one to beat Army!

Over thecourse of the work out, I had 40 or more “Happy Birthdays.” And I worked up a sweat, all by 7:15 am. Imagine starting your day this way. Every day.

So if SEALTeam Physical Training comes to your town, be the first to sign up. Or, you know how thisworks, start one of your own. It’s morerewarding than you might imagine. Andbesides, man overboard drills in a Zodiac are fun.

Hooyah!

Photographs:Nick Strocchia (nick@nickstrocchia.com)

The Female Triad, Eating Disorders, Amenorrhea, Osteoporosis

2011-12-04T15:01:00.000-05:00

"It's not having what you want, it's wanting what you've got"
Sheryl Crow

Only the run to go.

Last week we started a 3 part series on the female athlete and covered some of the physical and physiologic differences between male and female athletes. Injury patterns and the contributions of estrogen and ligamentous laxity were also discussed.

This week the so called female triad is considered including eating disorders, amenorrhea and osteoporosis. I first broached eating disorders in the female triathlete in a blog I wrote for Mother's Day 5/21/2011 and it has become my single most widely read blog. Somebody out there thinks this important.

The Female AthleteTriad

Amenorrhea, disordered eating and osteoporosis define thefemale athlete triad. Although found atall levels and types of sports activities, the female athlete triad is moreprevalent in sports emphasizing prepubertal body type, perfection, thinness, revealing clothing and subjectivejudging. These sports include dancing,cheerleading, gymnastics, figure skating and distance running. These females tend to be in high pressureenvironments set up by coaches and parents. They tend to show driven personalities. They have poor nutrition knowledge and tend to be in families withhistory of eating disorders and abuse. The earlier the diagnosis is made the more likely treatment will besuccessful. Any female athlete showingone part of the triad should be evaluated for the other two partsimmediately. The true prevalence of thefemale athlete triad is unknown.

Disordered Eating

Disordered eating refers to a wide range of ineffectiveeating behaviors used to lose weight or achieve a lean appearance. This in itself is a multifactorial problembased on issues ranging from requirements for specific sports to disturbed selfimage. In non-athletes the prognosis fortreating an eating disorder is poor with 50% doing well, 30% relapsing and a10-20% mortality rate. There are nostudies specific to female athletes.

Restrictive eating behaviors such as voluntary starvationand binging-purging behaviors are only part of this problem. Many athletes will just not eat enough todeal with energy requirements for athletic activity. Severe caloric restriction reduces metabolicrate and causes changes in all organ systems. Anorexia nervosa is the diagnosis when the patient views herself asoverweight and restricts eating even though their weight is 15% below idealbody weight. Amenorrhea is one of theDSM-IV criteria for this diagnosis. Bulimia is a cycle of food restriction followed by overeating thenpurging.

In general eating disorders should be viewed as chronicillness with serious medical and psychological results. Treatment requires a long termmultidisciplinary approach involving physician, mental health practitioner andnutritionist.

Amenorrhea

The long recognized cessation of menses with physicaltraining was felt to be based on low body weight and low body fat. This is now known to be untrue. More recent studies have shown that exercisestress and energy availability both can cause disruption of the GnRH pulsegenerator and the subsequent decrease in LH as a more likely source foramenorrhea. The exercise stresshypothesis is based on high resting cortisol levels and blunted cortisolresponses to exercise in amenorrheic athletes. The low energy availability hypothesis follows studies whereeumenorrheic trained women showed suppressed LH pulsatility after 3 days oftraining while dietary intake was reduced, but not suppressed when dietaryintake was supplemented. Several otherstudies have supported these findings.

Amenorrhea is the easiest symptom to recognize in the femaleathlete triad. Exercise associated amenorrhea is a diagnosis of exclusion. Reversal of amenorrhea is unpredictable soall women should be screened for pregnancy as part of their workup. There is an observed decrease in bone mineraldensity in non-menstruating athletes which predisposes them to stress fracturesand osteoporosis later in life. Calciumsupplementation of at least 1500 mg a day should be encouraged in amenorrheicwomen. Treatment for athletic amenorrheashould begin after missing 3 consecutive menstrual cycles. If the athlete is within 3 years of menarche,treatment should involve decreased physical training and supplementednutrition. If the athlete is 3 or moreyears post-menarche, low dose oral contraceptives should be considered.

Osteoporosis

Osteoporosis is characterized by low bone mineral density(BMD) and microarchitectual deterioration of bone tissue. Studies confirm higher incidences of injuriesand stress fractures in amenorrheic and oligomenorrheic as compared toeumenorrheic athletes. Since the femaleathlete triad occurs during the most important years for women to build theirmaximum BMD, the question becomes whether this problem can be reversed. Several studies do report increases in BMD inamenorrheic athletes resuming normal menses but these gains may belimited. Amenorrheic athletes usinghormone replacement therapy at doses used in post-menopausal women have shownmaintenance of BMD but no gains. Weightbearing exercise has a positive effect on BMD but it is not a largeincrease. The positive effects of weightbearing exercise in amenorrheic athletes are negated. Athletes suspected of the female athletetriad should undergo DEXA scan to confirm BMD status.

The Female Athlete, Part 1

2011-11-27T14:02:00.000-05:00

"Between two evils, I always choose the one I haven't tried before.
Mae West

The objectives of the next couple of blogs will be to discuss the female athlete from the position of the team physician. What is she/he thinking of when providing care? Specifically, what are the gender differences between female and male athletes? And, we'll look at physiologic differences, the female athletic triad and the effects of training on the pregnant athlete.

No longer should we be discussing the advances women havemade in athletic activity and competition. We now must push the knowledge base for female athletes to the samelevel as male athletes. The recentdecade has given us much information on treating the female athlete usingevidence based medicine but much still needs to be learned.

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Athletes: Male vs. Female

The significant differences between male and female athletesbegin just after 10-12 years of age. Theadvent of puberty starts these changes.

Females reach peak physiological and skeletal maturity before males.
Females develop more body fat and less lean body mass than males.
Females have less upper body strength even with training but lower extremity strength is much closer in parity with males.
Although males have greater red blood cell counts and hemoglobin levels, work capacity studies show minimal differences in oxygen uptake when body size and composition are equally compared between males and females.
Women have a wider pelvis and lower extremity alignment different from men that may predispose to injury.
Women have shorter limbs relative to body length than men.
Women have increased ligamentous laxity compared to men.

Both males and females go through the same physiologicchanges with athletic training and can gain significant increases in strength,power and muscular endurance. This istrue even for the aging female athlete where studies show that exercisetraining can still increase the size and strength of conditioned muscle.

Women are at greater risk than men for anemia. Decreased iron stores are found in 40-50% ofadolescent female athletes without the presence of overt anemia. Runners are at greater risk during theirtraining season. Black female runnershave twice the incidence of iron deficiency anemia of white adolescent femalerunners. In making the diagnosis of irondeficient anemia, be sure to differentiate this state from sports anemia whichresults from expanded plasma volume with a normal red blood cell count. Although only female athletes at high riskfor anemia or those with history of anemia should be screened, some feel that all femaleathletes should be taking iron supplementation.

Injury Patterns inFemale Athletes

The NCAA has been collecting injury data since 1982 for bothmale and female athletes. It is hard tocompare even on a sport to sport basis as there are different rules anddifferent activities even within some sports like gymnastics and lacrosse. In soccer and basketball were activities,rules and equipment are similar, females injury rates are 2.6 times greater insoccer and 3.6 times greater in basketball. In fact soccer followed by spring soccer show the highest rates forfemale athletes where for males football and lacrosse show the highest injuryrates. Consider the following facts.

The ankle is the most commonly injured body part in both males and females.
Females sustain 4.9 times the ACL injuries; 2.5 times the collateral ligament injuries; and 1.9 times the meniscal injuries compared to males.
The majority of ACL injuries in females are of a noncontact mechanism.

The higher knee injury rate for females is well establishedand probably has a multifactorial reason. The simple diagnosis of anterior knee pain is much more common infemales and most easily explained by the physical changes that occur to thepelvis and lower extremities during adolescence. This may also be part of the reason for theincreased rate of ACL tears in females. Femoral anteversion, external Tibial torsion and foot pronation of thefoot combine to create much greater stress on the ACL than in male athleteswhere the straighter leg can rely on the more dominant hamstrings for support. The hormonal influences and laxity combinedwith the above mentioned alignment issues lend to greater injury to theligaments which in turn increases the risk to meniscal and articular cartilage.

Studies have shown that plyometric jump training programsfor female athletes can increase hamstring strength and approximate malehamstring-to-quadriceps isokinetic testing. This improves jumping heights and is suggestive of protecting the ACLbut final outcomes are still unknown.

There are also studies showing estrogen receptors withinligamentous structures. Estrogeninhibits type I procollagen synthesis and proliferation of fibroblasts in vitrobut in vivo functions are still unknown.

Upper extremity injuries also are influenced by thedifferences between males and females. Shoulder laxity in swimmers, gymnasts and cheerleaders forms as avicious cycle of overhead activity combined with physiologic instabilityleading to impingement and rotator cuff weakness. Laxity issues also contribute to elbow andwrist injuries particularly in sports with aerial maneuvers where the upperextremity may become a weight bearing limb.

Smiles abound at the Underpants run in Kona

Next time we'll discuss The Female Athlete Triad of: - disordered eating

- amenorrhea

- osteoporosis

Thanks to Bill Vollmar, MD who first piqued my curiosity when he presented this data in 2008.

What's Possible For You In 2012?

2011-11-23T16:10:00.000-05:00

"I Felt So Good, Like Anything Was Possible"

Tom Petty and the Heartbreakers, Runnin' Down a Dream

The finish line in Kona about 12 hours after race start.

"ANYTHING IS POSSIBLE" This is one of the catch phrases of Ironman, one you hear frequently in Hawaii. You both hear it as well as see it. Some even live it.
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Speaking of the finish line in Kona, have you read Iron War by Matt Fitzgerald yet? If not, it's an excellent read and could be that perfect gift for someone for Christmas.
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There are so many heart warming stories that come out of this race each year. A good number of the first timers do not meet their expectations and on the morning after the race, honest evaluations of the heat and conditions seep into the conversations for the first time. "Mother Nature always bats last," or some such phrase might be overheard. In spite of this, the athletes share this common bond with the island as they lean back, close their eyes and recall particular portions of their day...both bad and good. And then they smile. That wry smile that comes only with experience.

The above photo is from ALII DRIVE, the finish line, where so many stories evolve. You hear them on race night, "I was just cruising down Alii Drive, man!," or at the Finishers Banquet, "The huge party at midnight at the finish line on Alii Drive was just awesome." Alii Drive, milepost zero, where it all starts and finishes.

By any other name it will always be Alii to the finishers:

NOVEMBER - Dreaming and planning time.

You know how on January 2nd, when you can't get a locker at the health club or gym, and you're used to having light conversations with the regulars, but now there a lots of new folks and the air is almost festive with excitement? Unfortunately, you know from experience that in 60 days it'll be back to the same old crowd.

Triathletes are the same...dreamers all, and at this time of year, they're reviewing recent races, successes and failures, saying, "If I can train just a little harder next year I can take the age group...or get that slot..." Maybe what they need is to train smarter not harder, to reduce garbage work outs, to reduce injuries, or at least be able to train through them. Listen to the words of folks like Ben Greenfield, Gordo Bryn, Adam Zucco, or Mark Allen on Line to name a few on how to minimize your down time getting a hold on injuries and returning to plan as quickly as is safe. In other words, create your plan mostly with your head and not your heart. Come race season, maybe if you're lucky, anything will be possible.

Next week, back to business as the triathletes injury resource. Happy training everyone.

Magic In Your First Race

2011-11-17T12:38:00.000-05:00

Do You Believe in Magic? Lovin' Spoonful

From USA Triathlon magazine *- With so much out there to read, I wouldn't be surprised to hear you missed this page. I found these entries quite refreshing and thought I'd pass them along.

The Big Question: if you could go back and change one thing about your first multisport race, what would it be?

I would learn how to un-clip from my bike, so I wouldn't fall over and take down the entire transition fence...pre-race. A. S. Atlanta, GA

I would not wear my mesh running shorts and non-moisture wicking shirt underneath my wetsuit. After all, soaking up water like a sponge while flailing/swimming like an injured seal isn't much fun. Not to mention that my first race was the Chicago Triathlon. J.S. Chicago, IL

Bring the correct tool to take my back tire off. Ran 6 miles with my bike. T.A. San Antonio, TX

Actually go for a swim in the ocean before the day of the race for my first triathlon. Boy, that was a surprise. Salt! Waves! People! Feet! No wall to push off! Pfew, it was rough. A.A. St. Petersburg, FL

Lost my timing chip and did not realize it until a buddy pointed it out 5 minutes before the gun. Ran back to the transition area, rifled through all my meticulously placed items - gone. Would I be allowed to race? Sprinted back to swim "Start" and dived in. Found the timing chip under my bed at home AFTER the race. J.E. Portage, MI

I wish I would have practiced running after riding my bike. Needless to say I quickly learned why they call it a brick - my legs were as heavy as bricks. I puked 4 times. I was a mess. N.W. Locust Grove, VA

I would not have worn a Speedo. It was 1983...be like Dave. G. W. Portland, OR

I wouldn't change a thing. The feeling I experienced when I crossed the finish line in my first triathlon is what got me addicted to the sport. Always been a cyclist. Hated running and now love it. Never could swim farther than 25 meters without stopping. now I can swim over a mile. Life-changing! M.O. Mahomet, IL

*USA Triathlon Fall 2011

In my mind, there's so much information in print that if these authors had read some of the basic triathlon literature, they wouldn't have made these errors. On the other hand, what better way to learn something than to screw it up? And if pain or a little inconvenience is part of the lesson, it will be burned in one's brain forever. I think that if you get out there, race, put it on the line, that each time you toe the start line you're a just a little more experienced. Before long you'll be the one writing the blogs!

With Thanksgiving coming up next week, do you already have a plan in mind where appetite control is king? The temptation to graze all day is pretty strong at at our house and likely yours too. Empty calories from too much alcohol, Aunt Mary pushing a third piece of pecan pie, that plate piled high with homemade chocolate chip cookies (any idea how many calories are in just one?*), plenty of snack food as you watch Green Bay and Detroit or the Fins take on the Cowboys in the late game. Just remind yourself, if Matt Fitzgerald, author of Racing Weight (and Iron War - terrifically written and great Christmas present to anyone who "tri's") was sitting at the table next to you, how hard would he tell you your next work out would have to be to cancel out what's going in your mouth?

"A minute on the lips, a lifetime......"

*Calories in chocolate chip cookies vary widely from as low as 55 to over 200, with 8 grams of fat, for ones that are homemade with real butter. Yum. Just one cookie!

Microfracture Update/74 Years of Triathlon Experience

2011-11-13T20:18:00.000-05:00

Experience Counts For Sure

Joe Friel, USAT Coach #1* and Bob Scott, Kona Course Record Holder discuss tactics about 30 minutes before the gun in this years race in Kona.

*Inaugural Co-chair of USAT National Coaching Committee.

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Safety Note - I saw a gent riding his bike down the street recently, no hands, talking on his cell phone, paying absolutely no attention to what he was doing or the cars coming up from behind. You talk about a recipe for disaster! I'm hoping this is never you.

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Microfracture Update - I've done a couple of blogs pertaining to microfracture in the past two years. For those of you who missed them, it's a technique performed arthroscopically when the surgeon encounters a relatively small and contained area of arthritis, frequently performed during knee arthroscopy.

See: Microfracture in the Triathlete, 3/7/09

Osteochondral Autograft, 11/13/10

Briefly, the surgeon employs a tiny awl to make 2 mm holes in the arthritic area of the bone to stimulate a healing response. The area is usually surrounded by normal healthy cartilage but the new tissue that forms after microfracture is more like a scar cartilage, one that will not be permanent , but may give the owner of knee a few more years of use.

Surgeons have tried a number of different options over the years to try and make this a life long repair. OATS, Osteochondral Allograft Transfer is one attempt. It allows the operating surgeon to transplant normal articular cartilage from one part of the knee to another. But, the indications are pretty narrow.

In this months Journal of Arthroscopy and Related Research a study by Steadman, et. al. discusses the use of stem cells (See my blog from 10/25/2011) to augment microfracture. They note that "Arthroscopic and gross evaluation confirmed a significant increase in repair tissue firmness and a trend for better overall repair tissue quality..." Although this particular study was done in horses, I suspect that further studies using a human model are right around the corner. Physicians have been harvesting stem cells (frequently from an area of the low back) and re injecting them for a variety of conditions over the years. One such treatment is called Regenexx ( see www.regenexx.comm) where, for a host of conditions, the non-surgical use of stem cells seems promising in the short term.

74 Years of Triathlon Experience - As we head into the "off season," the opportunity to tremendously increase our knowledge base is here. I've been involve with triathlon for almost 30 years and one of the things that strikes me is that we seem doomed to repeat mistakes made by others. The training road you're charting now, to get you to the starting line at your first race in 2012 has been walked before you. If you can simply learn from the encyclopedic experience of Gordo Byrn in "Going Long," or tri related weight control of "Racing Weight," from Matt Fitzgerald or "Your Best Triathlon," by Joe Friel, you'll be ahead of the game. Way ahead. Or, see if you can't find a triathlon seminar not too far from your home, particularly from someone you know little about, where the opportunity for learning something new is right up front. Even Bob Scott and Joe Friel are searching for knowledge at this time of year. Barnes and Noble here I come.

Image 2, Google Images

2012, Your Best Year Yet? Dealing With Injuries.

2011-11-07T11:36:00.000-05:00

AS WE BEGIN TO PLAN FOR NEXT YEAR....

Underpants Run, Kona, Hawaii 2011

"I don't know what I've been livin' on but it's not enough to fill me up. I need more than just words can say, I need everything this life can give me." Best of Both Worlds, Van Halen
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In one sense, Van Halen is speaking (singing?) directly to the triathlete. We give a lot to the sport, we get a lot from the sport. But, if we can just take a minute or two off of that 40 K bike next year, then....who knows, maybe a tri PR! For many of us, this time of year is a time away from triathlon. A time where, like so many of the pro athletes, we take a complete break from swim-bike-run. It's basketball, squash, water polo, golf, anything that's not what you do the other 11 - 11.5 months of the year. A chance to cleanse the mind, fuel the fires for the future, and to dream about what might be in 2012. Dreams are important. Just ask Freud!

Perhaps your bike will resemble this one soon.

Preparing That Annual Training Plan With Previous Injury in Mind

Since it was below freezing on our bike ride this morning, much of the triathlon world is probably finished racing, fretting about next year and wondering where to begin constructing an Annual Training Plan, especially if a history injury is involved. Unfortunately, statistics would say that even if you've been involved in triathlon for just a few years, your probability of sustaining an injury is nearly 100%! So now is the time, before you've done work out #1 preparing for the 2012 season, to review all available data from 2011 and see if you can both figure why your injury occurred and what you can do to avoid it (and others) in the upcoming year.

Running, of course, is the source of over half of triathlon injuries. This is particularly true when twisted ankles or bike crash related type trauma is excluded. And, in my mind, one of the hardest things in this search for causation is honesty. Self delusion is a well practiced skill for those who race. "Well, it hurts, but not so much that I can't keep trying to catch that guy up there." (Sound familiar?)

But the athlete's whole focus is attempting to get their body to bear a greater load, to accept a higher level of stress for the same effort expended. Thus, greater speed is the outcome...and potentially a podium finish. So, it's these changes in stress, increases at a tolerable rate, that get us there. It's determining this rate of change that's the tricky part, however. Why do you think there are so many stress fractures and other stress related injuries, etc. in our sport?

It's being honest in recognition of previous changes in routine. Not just glossing through one's log thinking, "Oh, I should be able to handle this or handle that," when in fact you can't. And the change doesn't need to be Herculean. I've seen stress related injury after a single aberrant run. For example, George goes to the beach and does his weekly 10 mile run in the hard packed sand, seemingly a soft (read non-concrete) surface and great idea. But running out bound 5 consecutive miles at water's edge and back on the beach road, while softer on the feet, is really running 5 consecutive miles on the side of a shallow hill. This is very different from the ever changing surfaces and angles that Georges legs see when he runs at home. Or, Sally is in Chicago visiting Aunt Minnie for Thanksgiving and gets fixed up with the local running group, all a tad quicker than Sally. She executes her weekly 10 mile run with the group, pushed to her very limit, but quite satisfied at run's end with her "much better than I thought I could do" performance, her ability to draft, to keep up despite being near exhaustion, etc....until pain develops some time later. It's not easy for the body to accept change.

Thus when planning for 2012, review the musculoskeletal changes that didn't go as you'd planned, include them in your thinking, maybe even talk it over with your "shoe guy" or other trusted advisor. I've said in these pages before that the owner of our local running shoe store is the go-to-guy for running related problems locally. He's better than most all of the docs that I know. If you run your plans by him (her) you stand a much better chance of not repeating the same mistakes next year.

They say that knowledge is power*. That's nowhere more true than in building an ATP. Good luck in your planning. Maybe these folks from the Underpants Run (below) can help you.

*Or, in some circles, Ex Tridens Scientia. From Knowledge Sea power.

Raynauds and Winter Training

2011-10-30T12:56:00.000-04:00

Perhaps the owner of this bike has something else on his/her mind!

Smith and Wesson?? Do you ride it or shoot it?

Although it’s only October, we in Virginia have had our first snow of the year. I think it’s a good time to start this year’s discussion of cold hands, Raynaud’s Syndrome in some cases.

Raynaud's is pretty common. Many will have it as an isolated phenomenon and in others, it accompanies a more global process. Those affected will have more issues in the cold conditions than warm, their fingers will have decreased sensation and turn white, almost snow white, on occasion. When placed in modestly warm water for 2 or 3 minutes, the digits re-warm and turn every shade of red and purple you can imagine before simply settling on only mildly red. Once warm, starting a car is easy.

If you want to document this, next time it occurs, start taking pictures with your cell phone, and save them for your health care provider. You will asked about a family history of certain kinds of arthritis, bowel disease and the like. You may find that your complaints are the same (or different) but it's a good starting place.

My sister and I both have this to a greater or lesser degree and I think I'm the biggest purchaser of chemical hand warmers at our local backpacking store. But, I ride outdoors all year unless there's snow or ice on the road. Cold water swimming, however, can present a certain challenge!

For those readers who may not know (or who may have it and wonder) Raynauds Syndrome is the discoloration and numbness of the fingers that many adults see in response to cold (or sometimes changes in emotion.) The finger whiteness discussed above, sensory disturbance, and even pain, make them pretty useless when trying to type or any other fine motor activity. In a few minutes, as the fingers begin to warm, they turn blue then a purple-red with a "pins and needles" feeling before they normalize. This whole process can take from just a few minutes to an hour and can be quickened by immersing ones hands in warm water as noted above. Or stick them in your pants. Women seem to get this more than men, 2nd to 4th decade of life. There are medical answers to this, and especially medicines to avoid, which might increase the frequency of attacks.

That said, I've had it for 30 years, my Mom longer, so it's easy to follow long term. And mostly we just live with it. I use chemical hand and foot warmers biking in the winter, and when it's below freezing I have some Sidi rechargeable warming inserts for my winter biking boots (they're not cheap and don’t work all that well - read don't waste your money). It's all just a matter of preparation. So, welcome to the world of Raynauds Syndrome, it's an inconvenience but not much more.

A number of readers have had excellent posts about how to solve the cold hands problem that can accompany winter riding. Excellent suggestions have come forth about a variety of different types of gloves/mittens/socks, chemical hand warmers, etc. Some athletes have simply chosen to ride indoors until the bloom of Spring and give those Computrainers a work out. If, however, you want to stay outside all winter, depending upon your climate, some alterations may be in order to remain comfortable.

As we've noted here before, a surprising number of athletes suffer from Raynaud's Syndrome, a spasming of the small arteries in the digits, often when cold. About 5% of men and 8% of women have Raynaud's and it can affect ears, toes, and even your nose.

So, to remain comfortable we have to remain warm. All it takes is a little trial and error. Well, maybe a lot of trial and error. I'd suggest you start by putting a thermometer outside your window to get an accurate temperature before you venture out. It's better than the Weather Channel as you may live a real distance from where they get their measurements. Then, get an idea of what gloves, layering of gloves, mittens and layering/lining of mittens you need at 50 - 55 degrees, 40 - 45 degrees, etc. If your mittens are so bulky that you may lose control of the bike, figure out something else. A reader from last year noted that the important thing was not to layer each digit as you might do with shirts and coats, but to provide a “den” for the fingers. Mittens, more than a single layer, with touching digits and some type of warmer seemed best for him. One thing that many over look is a product called Bar Mitts (they also have Mountain Mitts for your mountain bike.) These are sleeve-like neoprene that fit right over your handle bars and block cold, rain and snow...not that you'll be riding outdoors on 23 mm tires in the snow. I hope. You don't even need very thick gloves to stay toasty. I'll admit that they may look a little dorky but the bike group conversation will quickly move on to something else and you keep your hands warm. I'll attach a couple pictures from a local riders bike.

Reader Darkwave added these very useful comments: I've found disposable hand warmers to be essential for winter running -- I start using them when the temperature drops below 50. For running races, I wear thin gloves, then hand warmers, and then socks over both. If I heat up too much in the race, I can toss the socks or even the hand warmers.

As always, please share your experience and comments.

Concussions Off the Bike

2011-10-27T12:13:00.001-04:00

Substitute Swimmer for your Triathlon Relay?

Kimo the dog. I wear glasses, but my eyesight's not all that bad. While treading water at the Coffees of Hawaii barge (every year during IM race week in Kona, the good folks at Coffees of Hawaii set up a large sailing craft about 700 m off shore, where anyone who swims up

Coffees of Hawaii barge

to it is offered a small paper cup of Kona's finest. It's pretty darn cool and I'd suspect they serve over 1000 "customers" each morning. And the coffee's hot, too!)

So, while sipping my excellent brew, goggled, without glasses, I noted a group of three swimmers approaching, one with a very odd mask on, but hey, it's Hawaii, home of the underpants run. And I'm in the middle of the ocean at a coffee barge for gosh sakes. I thought the mask had ears on it. But, once they were closer, I could see that the third swimmer was a German Shepard...with a life vest on. Now there's something you don't see every day back home. When they had their fill of coffee, all it took was a simple, "Come Kimo," and off they went, continuing their swim.

ACL Reconstruction Follow Up
In August, I did some reporting on ACL (Anterior Cruciate Ligament of the knee) tears. Reuters reported this week, in a study of Australians followed for over three years following their reconstructions, that "half of people who played sports competitively or just for fun don't perform as well as they used to." When narrowed down to those who played competitively pre-injury, only 91 of 196 returned to their competitive sport.

While this is a single study, and review of many give a more representative picture, suffice it to say that tearing an ACL can be a serious injury.

Concussions Off the Bike
Who among us hasn't been on a group bike ride where there hasn't been a crash of some sort? If you were lucky, it was just a little road rash. If not, a portion of the injury could be a head injury. And this is true for helmeted cyclists as well. Not infrequently a concussion will occur and this has the potential for being a more serious injury than we may have previously thought. The October 10, 2011 Sports Illustrated has an article on the NHL which discusses the head injury to it's "most important star" Sidney Crosby. They are rededicating themselves to player protection, and we should too.

But haven't we always had the culture of endurance over safety? Haven't we seen the films of the last 400m of IM Hawaii where Paula Newby-Fraser, the Queen of Kona is weaving down Hualalai Street like some kind of drunk when Karen Smyers sprints by? Or Chris Legh, or Wendy Ingraham and Sian Welch, as they weave uncontrollably toward the finish line? Maybe they've crossed a line of a different sort! In the mid 2000's, I had the slowest bike time of all 1700 competitors in Hawaii when I stopped to help a biker on the down hill from Hawi whose front wheel had hit one of the plastic highway road reflectors at just the wrong angle. POW! Instantaneous crash, broken helmet, closed head injury, you can guess the rest as we waited for rescue help together. In short, once a concussion is recognized, that athlete's day is done - they should not be allowed to resume their sport, triathlon included.

Research is showing that healing of injured brain tissue requires sufficient nutrients and rest. If this isn't allowed to occur, then the potential for increased injury increases. Previously, injury severity scales left a great deal of interpretation to the examiner when deciding how serious the concussion really was. Now, especially in NCAA sports, if a player suffers a concussion of any magnitude, he or she is out of the game. No questions asked.

So, as an athlete, how do you determine if your bike mate's had a concussion after that crash? Well, you're probably not a neurologist, but starting with an "index of suspicion," at least considering that it's possible helps. Was there a loss of consciousness, confusion, head or neck ache, blurred vision or anxiety? In an athletic contest, the athlete would be asked, "Who Scored last?" or "Where are we playing today?" Finally if the suspicion continues, the player would be checked for balance and coordination. Now, I'm not saying that every time somebody in your bike group goes down that you start this cascade. But what I am saying is, as a friend of somebody who's had an accident and my not realize that they've suffered a head injury and are not making the best of decisions, you need to take charge. Nice the injured rider into calling a day, just because, and give them a ride home. Likely, a trip to the local ER just to be on the safe side would also work Then, maybe after all that, it gets to be Miller Time.

Image 1, Google Images

Stem Cell Transplants

2011-10-23T13:19:00.000-04:00

The View From T1 in Kona

"I have no reason to be over optimistic, but sometimes when you smile I can brave bad weather." Tommy, The Who

How can you help but not smile when you share the frivolity of 23 year old age grouper Brian Yannutz who puts a shark fin on his bike helmet? (I think it was ultimately removed by race officials prior to race start - safety.)

One of the advantages, and disadvantages, of working on the pier during IMH is that you not only see the race unfold, you're close enough to touch the athletes. Or, in some cases, be "touched" by the athletes as they smash into you having exited the swim and slightly misjudge the turn into the men's changing tent where you're directing traffic. But, you quickly guide them inside with a friendly comment so they can don bike gear and head to the Queen Ka'ahumanu Highway and the heat and winds that await them on their 112 mile journey. As the race progresses, you see not only their splits, recorded for eternity, but you see the expressions on their effort filled faces, maintained for only an instant. Are they springy and smiling as they exit T1 - most are, or do they seem tired but gritty with determination as they hand off their two wheeled steed to the volunteer bike catcher at rides end? Are their black shorts covered with salt? Do they wave to the adoring crowd or merely take the next laborious step as they head out on the the run? Body language, it's everything isn't it?

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Life Giving Stem Cell Transplant

You've seen the newspaper articles concerning the "miracle" of stem cell transplants. And, in many cases, it truly is nothing short of that. Stem cells are juvenile cells which possess the ability to grow into red and white blood cells, platelets, etc., and one day possibly nerve cells and more for the treatment of brain and spinal cord injury and so forth. Currently, the main source of these cells is from human bone marrow as they're used in the treatment of leukemia (body makes too many young white blood cells) or anemia (blood cell production slows or ceases) and various other types of blood related disease processes. 14,000 or more bone marrow transplants are done in this country annually. But, one of the major hurdles for these patients is finding a donor, an exact match. This is especially true of those of southern European of African ancestry where the match rate can be as low as 15%.

Along comes umbilical cord blood which significantly improves the potential of finding a match! The source of nearly half a million possible donors annually comes from the National Marrow Donor Program and Eurocord, organizations which arrange for the placental and umbilical cord blood of new borns to become part of the universal blood bank pool. In the past, these were discarded but now, with the mothers permission, they can be harvested to help others. Thousands have benefited from this new source. In other words, it's prevented thousands of deaths of those who otherwise wouldn't find a match!

What Triathletes Can Do Become a possible donor. It's easy. Since upwards of three quarters of those who can not find a living related donor turn to the Donor Program, you can be there to help. Simply go to www.marrow.org where you'll find:

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Join Now

Thousands of patients hope for a bone marrow donor who can make their life-saving transplant possible. They depend on people like you. You have the power to save a life. Take the first step today.

Do it today!
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I'll leave you with this: Charles Shackelford, former North Carolina State basketball player noted, "I can go to my left or my right, I am amphibious."

Pain and Pain Medications

2011-10-16T22:12:00.083-04:00

A "Thank God I'm Not Racing!" Party in Kona? Say it ain't so.

Site of the 2010 TGINR party

I briefly mentioned the "Thank God I'm Not Racing Party" in Kona hosted by Competitor Magazine in my 10/4/2011 blog but as best I can tell it wasn't repeated this year. Too bad as I think it's a terrific idea along the lines of the Underpants Run. These are things that just seem to fit in the Hawaiian ambience but might be hard to duplicate at other race sites. Jessi Stensland wrote on Active.com that "There's always a reason to celebrate in Kona and last year's first (hopefully annual) TGINR "Thank-God-I'm-Not-Racing" party, hosted by Competitor Magazine on the eve of the race is a perfect example. The inaugural event, held at Huggo's On The Rocks, was packed with pros, supporters and other industry folks. An open bar, buffet and baseball caps with TGINR were free for all."

Maybe if we're lucky, the TGINR party will reemerge in 2012.
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Might be you one day!

Ankle fracture weeks before "A" race Ironman

"Sickness will surely take the mind, where minds don't usually go. Come on the amazing journey, and learn all you should know."
Tommy, The Who
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"At some point in your triathlon life, you may have some type of injury such that you're in enough pain that some sort of pain medication is offered/requested. So many of us are resistant to the "there's a pill for that" mentality but we're addressing situations which are out of the ordinary and by using the suggested medication, perhaps other parts of life will benefit like amount of sleep, ability to exercise, spousal relations, etc. There are many options, and if you have a general idea of what might work best for you ahead of time, then you'll be neither over nor under medicated. Let's look at some of your choices.

Aspirin

Anacin, Ascriptin, acetylsalicylic acid and other forms of this work horse medication have been around for decades and have found wide acceptance as an analgesic in the treatment of minor pain. Either alone or in combination with or substances such as narcotics, it's proven most effective. It also finds use as an antipyretic (lowers temperature,) an anti-inflammatory agent and most recently as an anti platelet drug in the prevention of myocardial infarction's, strokes and blood clots in low doses. The author takes a daily baby aspirin (81 mg) for just such an indication. It's primary negative is the occasional formation of GI ulcers or stomach bleeding. It's one of the most commonly used medications world wide.

Acetaminophen

Tylenol, like aspirin, is an analgesic (diminishes pain) that's available without a prescription and is useful in treating minor pain and flu like symptoms. It also finds it's way into combination drugs like narcotics for more severe pain such as post operative, obstetric, or in those with cancer pain. It is not an anti inflammatory and does not share the same side effects as aspirin. But, if inflammation is part of the presenting symptoms, then acetaminophen may not be the best choice. In chronic use or larger doses, it can be potentially fatal to liver function, and is a common cause of death in those who've taken a drug overdose. It is quite safe when used appropriately.

Non-Steroidal Anti Inflammatory Medications

The NSAIDs, Motrin (ibuprofen), Naprosyn (naproxen),Clinoril (sulindac),Celebrex (celecoxib), etc. as they are called, can be quite useful in treating chronic or arthritic type pain as well as acute pain. Like aspirin, NSAIDs also have the ability to lower temperature. Their primary role in in the treatment of inflammatory conditions, the -itis's, as in tendinitis, bursitis, etc. Once again, occasional GI distress is the major potential side effect and is reported to be less the family of drugs like Celebrex, a COX-2 inhibitor. As with any medication, you should take it when needed but stop when you don't.

Corticosteroids

In select circumstances, these anti inflammatory agents like prednisone, Medrol Dose Packs, etc. can be quite effective over short durations. They are not to be confused with anabolic steroids like the weight lifters have reportedly used. You might be given these orally or as an injection into a joint or a tendon sheath. Side effects can be elevated blood sugar in diabetics, weight gain, and adrenal suppression. Careful here.

Narcotics

Widely prescribed by the medical system, drugs like morphine, codeine, hydrocodone,etc. find a role in controlling more severe pain. They require special licensing from the Drug Enforcement Agency to prescribe but help patients through surgery, migraines, deliveries, trauma, etc. They should only be taken when the above options prove ineffective. On the downside one finds the possibility of tolerance if taken for a long time, addiction, abuse, etc.

Alternatives

In many instances, simply starting with ice and/or heat can make a big difference. And, this list of categories is not meant to be exhaustive. Electric stimulation, acupuncture, massage, physical therapy, etc. may play a role in your care.

In conclusion, depending on your situation, if in pain, and asked to consider one or more of the above options, work with your health delivery team to determine which of the above agents might be best for you.

E.S.I.'s/Back Injections

2011-10-13T09:47:00.001-04:00

Incredible Octogenarians in Kona

I really enjoyed the awards banquet in Kona on Sunday. Many smiling, happy age groupers and pros who'd done well enough in the previous days Ironman Championship (they've dropped the word triathlon in most places) to earn a spot on the stage and a special podium prize. Our seats were close

enough to the competitors and "voice of Ironman" Mike Reilly (Who was inducted into the Ironman Hall of Fame Sunday,) that it made for a terrific night. The final athletes to stand astride the podium were the 80 and over age group. That's right, 80 and over. 2010 saw the first man over 80 to finish the difficult Hawaiian course known for it's heat, wind and barren lava fields. Lew Hollander, a gent who could pass for 65 any day of the year, who's competed in and finished 20 IMH's, crushed it with a 15:48 finishing ahead of 39 other racers. (Interestingly, the last athlete across the line finished in 16:59:13, a mere 47 seconds ahead of the 17 hour - midnight - cutoff!)

Lew took the age group again this year ahead of two other 80+ year old finishers, and it would have been 4 of 4 if Bob Scott, reigning 75-79 year old course record holder, hadn't had bike rear tire alignment issues. Can you name any age group where they all finished? You realize that it wasn't that many years ago that 60 was considered old, over the hill (way over), in Ironman terms yet I watched 75 year old Harriet Anderson, also a finisher this year, beaming with pride after being handed her award from Heather Fuhr, 1997 World Championship winner. Formerly grand old men Bill Bell and Norton Davey gave Kona a good shot, both Ironman finishers at other locations, but the infamous conditions proved overwhelming. Our hats are off to these fine folks who refused to give up despite the odds against them. We should be so lucky!
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Epidural steroid injections and back pain. Sound familiar for some reason?

Back pain is present everywhere.
There are 15,000,000 visits to the doctor annually.
95% of us will have at least one episode in our life time.
Back pain is seen in 50-80% of the population at any one time. 20-30% of athletes.
The annual cost of management is 50 Billion dollars.

For those in pain:

80% of the cost is in those with chronic back pain which makes up 10% of patients. So who's at risk? Well, complaints begin to increase at about age 35 increasing till about age 50 in males and 60 in females. While there is thought to be some type of genetic component, other risk factors include general fitness, core strength, which certainly plays a role as does type of work place or sports, depression, and cigarette smoking to name a few.

Perhaps you've been diagnosed with sciatica defined by WebMD as: "Pain resulting from irritation of the sciatic nerve, typically felt from the low back to behind the thigh and radiating down below the knee. While sciatica can result from a herniated disc directly pressing on the nerve, any cause of irritation or inflammation of this nerve can reproduce the painful symptoms of sciatica. Diagnosis is by observation of symptoms, physical and nerve testing, and sometimes by X-ray or MRI if a herniated disk is suspected."

If this is the case, your physician may suggest an ESI or epidural steroid injection. These injections are typically done under fluoroscopic guidance by physicians who specialize in spine care including Physiatrists, Pain Management centers, Anesthesiologists, etc. It takes a good bit of practice to get the very tip of the needle in the exact location desired to deliver an amount of corticosteroid (not anabolic steroid like it's been suggested that body builders use...or is it abuse?) Currently, one can recieve up to three of these injections in one years time if needed. This video may be helpful. http://www.spine-health.com/video/epidural-steroid-injections-back-pain-and-leg-pain-video

While relief of pain is seldom permanent, it can, in many cases, be quite long lasting easing leg pain, back pain, or both. They've been used successfully in the neck, upper and lower back for over 60 years. If an ESI is in your future, I would discuss the experience of the person doing it along with potential complications to help take part in my own health care.

Calf Strains

2011-10-04T22:30:00.000-04:00

3 Days till Blast Off in Kona!

The triathlon press watch bike inspection carefully recording equipment details.

The streets here are alive with runners and bikers, tall ones, short ones, old ones, young ones. It's quite the site! I ran into Bob Scott from Naperville, IL this morning after his early swim. Bob is the course record holder in the 75-79 year age group (having previously held 65-69 and 70-74). He's racing 81 this year...we should all be so lucky. You may not know that Coffees of Hawaii sets up a barge about 700m off shore here, and as part of your morning aquatic adventure, they include a few ounces of hot Kona coffee to anyone who happens to swim by. It's really a treat. All part of the Kona experience. Also, Competitor Magazine puts on a Thank God I'm Not Racing party on Friday night that's exceptionally popular for all the reasons you might imagine. That said, come Saturday morning when their studly friends toe the start line, maybe there's a little different sentiment.
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Calf Strains
We recently covered hamstring tears and strains and I thought it a good time to review calf strains. When you look at the person in front of you's calf, the two main muscles are the Soleus and the larger Gastrocnemius. They function in ankle flexion, pointing the toes down. The gastroc originates in the back of the knee off the femur while the soleus originates off the back of the tibia and fibula.

I've had patients tell me that when they suffered a calf strain that there was no doubt in their mind that there was something wrong. "It was like somebody hit me in the calf with a golf ball going 500 miles an hour!" Depending on the level of involvement, symptoms can include swelling, bruising, pain, an inability to contract the muscle, limp, etc.

The Big Hooyah 2011

Pat McCann, a multiple time IM finisher, is see above participating in a local race called "The Big Hooyah" put on by SEAL Team Physical Training. It's one of those events run through the woods, fields, rivers, over and under obstacles. They've just finished pushing the hay bales seen in the back ground. Pat's had a number of both hamstring and calf issues over the years and finds, like many that carefully listening to his legs being careful not to overdo is key to his training. He also recommends keeping the calves warm when the temperature drops.

The current calf strain grading system, like hamstrings, has 3 levels or grades depending upon the perceived severity of the injury. Historically, the structure thought to be torn was a small muscle known as the Plantaris found deep in the calf. The advent of MRI changed that and accurately identified the medial (inner) head of the gastroc as the culprit. Grade 1 is the mildest form of this injury which even present in a chronic form. It's characterized by mild to moderate pain, little to no bruising with many athletes taking minimal time off, resolving in a couple of weeks.

The triathlete with a grade 2 injury is much more likely to display bruising and swelling, moderate to significant pain, and distress with attempted toe off. One of the Ironman favorites in the 50 - 54 year old age group on Saturday, Steve Maves, who runs a 3:08 marathon after a 5:12 bike, describes his calf tears as not occurring in the expected "runs too fast early without proper warm up" variety but more likely to occur in the middle of a work out when all is quite well warmed up. In fact, he once had one during warm down!

The most severe injury is the grade 3 tear. This involves a significant disruption of the muscle fibers, bleeding, etc. One is frequently unable to walk, did feel like they got shot in the calf, and can have enough torn muscle that it is visible cutaneously in the upper calf!

Treatment
Ice for the first 48 hours is most important thing, but being careful not to be too aggressive and avoiding frostbite. Many find elevation and rest helps them shorten the period of disability as well. Allowing the damaged muscles to heal before stressing them again pays off in the long run. Gentle stretching, but not to the point of pain, can be beneficial. The literature would support brief use of an NSAID like Ibuprofen.

After 48 hours, heat is applied and a physical therapist may be be employed to assist with tissue mobilization, ultrasound and an exercise regimen to re-strengthen the extremity. Commonly the grade 1 injury is resolved in a week to 10 days and grade 2 - the most common - in about 6 weeks. The grade 3 injury, in my mind, should be cared for by a physician, and can require 3 months, perhaps even 6 months to resolve. I know a couple folks who've had 2, even 3 calf strains in the same calf but fortunately they're frequently only grade 1 tears. Good luck

Heat Acclimatization

2011-10-02T21:35:00.000-04:00

Kona - One Week!!

       The desolate beauty afforded the biker on the NW coast of the Big Island of Hawaii.

Although when one thinks of the Hawaiian Islands, lush tropical forests come to mind. They may not be familiar with the Ironman course along the Kona Coast. As you can see, the harshness, almost moonscape appearance, gives one the feeling of being completely alone.
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For many of us, triathlon training is a similar emotion, but also one that pervades all aspects of our lives. Who among you hasn't been in a social situation, out to dinner with a client or halftime at an offspring's soccer game, and when the conversation slows, your brain drifts to how to improve your T1 time in your next sprint tri? Or, maybe you should go ahead and buy that swimming video your lane mate mentioned.

As one who's spent Ironman race week on the Big Island of Hawaii for each of the last 20 years, you get an interesting perspective of the "top of the pyramid" in our sport and what it takes to get there. I volunteer on the pier every year helping out in Transitions. I get to be part of a talented, dedicated team lead by capable David Huerta. While some of the athletes seem almost consumed by the sport, many see it as just one slice of the pie of life. Just a pretty big piece! Many have the ability, especially when their race season is complete, to put the lifestyle inclusive of 10, 15, 20 or more hours/week of training behind them, spend time with family, cross train by leaving the bike behind and go hiking with the kids, etc. Sounds like a healthy approach to me.
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One note. I learned just how far WTC goes to ensure a fair race and compliance with the rules. When the pros exit the swim and race to the transition tent, they are "helped" out of their speed suits by volunteers who then label each suit with a number. Later, when most of the athletes are well out on their bikes, each suit is inspected to make sure that it followed race guidelines - one was not! (And the entrant later disqualified.) They're pretty serious in Hawaii.

Very interesting to observe. Make sure you follow the rules.
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Heat Acclimatization

It's been shown time and again that heat acclimatization is crucial to an athlete looking for his/her best performance. Even if one spends only ten days acclimating prior to an intense effort in a warm environment, there is benefit to be reaped. According to TBC coach David Warden, "The cruel irony is that the age groupers are more likely to race in heat. They are more likely to be unable to train in a warm environment, they're slower and often get a start later in the day, all of which combines for a very long day. In short, Warden points out that "Since training should simulate racing conditions as much as possible, heat acclimation should be considered a part of the annual training plan." An interesting perspective for sure.

There's a certain concentration of electrolytes in sweat.  Thus, if the non-acclimatized athlete sweats more in the warm environment, they lose more electrolytes. Over a ten day cycle, it's been shown that the body can adapt to warmer temps by diluting the sweat concentration, preserving electrolytes.

It's also been demonstrated that there's a higher use of glycogen in the heat as well as increased concentration of lactate, and both of these can be brunted to a degree by allowing the body to accommodate to the changed warmer environment.

Lastly, since the athlete with little to no acclimatization measures has to cool his/her blood through the skin, there's a diminished amount of blood left for propulsion.  This actually increases the stroke rate, the heart rate, and can alter one's training zones by a significant amount.

So, the take home message here is to do what you can to get your body prepared for the environment in which you'll be racing.  The pay off will be the view seen above earlier in the day, a win-win for you.

Hamstring Pulls and Tears

2011-09-29T15:20:00.000-04:00

Reef fish near the swim start of Ironman Hawaii

"Hold on to 16 as long as you can. Changes come around real soon make us women and men"
John Mellencamp
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You're out for a run on a cold early fall day. Not much of a warm up. You sprint to catch up to the group when WHAM! It feels like you got shot in the back of the thigh. Maybe you fall, maybe only limp. But it's a big limp. Maybe you've suffered your first hamstring tear.

The three hamstrings are among the first leg muscles one studies in medical school. They're known as biceps femoris , semi-membranosus , and semi-tendinosus originating at your "sit down" bones extending to just below the knee joint. Functionally they provide for flexion power at the knee as well as extension of the hip.

This muscle group is frequently the source of pain and injury in both the endurance athlete as well as the more explosive sprinters or football players. As can happen in any muscle, the injury pattern can be graded with relation to the degree of severity on a 1 - 3 scale. Grade one injuries are a simple "pulled muscle," grade two comprise those with an actual partial tear of the muscle substance itself, and grade three are the most serious in which the muscle tears completely and surgery to reapir it may be under consideration. These injuries occur when the muscle is stressed to a limit greater than it can handle. Folks who have relatively poor conditioning are at risk for this injury as are those are overly "tight," ones who are fatigued or have a muscle imbalance. As you'd expect, simply the choice of sports can increase ones chances of suffering this injury when considering among basketball and soccer players, dancers, etc. Also a risk group are older adolescents whose growth has yet to be completed.

Grasping the posterior thigh in pain, the hall mark of this injury, can be accompanied by swelling, decreased strength of flexion of the knee, and bruising. Occasionally this bruising can be quite extensive (a little bit of blood goes a long way) as the athlete sees purple hues on the back of the thigh, knee, calf and sometimes all the way to the ankle. There's no doubt that an injury of significance has occurred . When they get to my office with this type of story, we examine the limb for the above bruising, areas of tenderness, and once in a while the examiner can even feel a gap along the course of the muscle. This is especially true when the muscle has pulled off it's bony origin. In some instances further information can be obtained from a plain x-ray. Less frequently, an MRI may be ordered to determine the actual amount of damage.

Treatment options are usually based around both the severity of the injury as well as particulars of the athlete involved. In most cases, a non-surgical regimen will be the order of the day. Short term crutches and cessation of the patients sport put the muscle group to rest and allow it to heal. Application of a straight leg brace furthers these efforts. Traditionally the use of cold therapy icing down the injured location a few times/day can also be beneficial and diminishes the pain to a degree. Many will use a 6" Ace Wrap around the thigh to keep further swelling and bleeding to a minimum, re-wrapping it several times/day, leaving it off at bedtime. We routinely recommend the patient, for the first 48 hours, try to spend time in a recliner elevating the limb, also with the intent of swelling reduction. Surgery is usually reserved for those who've avulsed (pulled off) the attachment of the muscle from the pelvis and those who've suffered a complete tear of the muscle belly itself.

At some point, the services of the local physical therapist may be of benefit to help mobilize the extremity, recover strength and develop a plan which minimizes the potential for re-injury. Depending upon the degree of the tear, the level of swelling, any history or previous hamstring injury, etc., athletes can be back to slow running in a matter of weeks where those who've required surgical repair can take 6 months, or more, to be back to full strength. This is one muscle group where the owner wants to follow instructions. If they don't, and suffer a recurrent hamstring tear, it can lead to a permanently injured muscle which never provides full function again. But, fortunately this is the rare occurrance as most get back to their original sport even it if does take time.

Image 1 Bryce Groark, 2 and 3 Google Images

Exertional Compartment Syndrome

2011-09-22T12:06:00.000-04:00

Some things are not what they seem.

"I met her in a club down in old Soho,
Where you drink Champagne and it tastes just like cherry cola, C-O-L-A cola.
She walked up to me and she asked me to dance,
I asked her her name and it a dark brown voice she said Lola, L-O-L-A Lola.

                                                                          The Kinks
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Many an athlete toils with the diagnosis of shin splints, periostitis, tibia stress fracture, compression neuropathy, tibial stress syndrome, etc. when what they really have is compartment syndrome.

Compartment syndrome is frequently manifested by pain with increased exercise as muscles swell in an unyielding sleeve of bone and fascia leading to a gradual pressure increase within this "compartment" and pain.  If you were to research the anatomy of this compartment you'd find muscles, vessels, nerves, etc. and as the pressure increases, on some occasions it can reach a level where blood flow is completely shut off and the contents of the compartment die. The picture above is a pressure measuring device as it about to enter the anterior compartment of the lower leg, a common location for compartment syndrome.

Look down at your right leg, feel the sharp bony crest of the tibia. The soft tissue to the right, extending around posteriorly to the fibula (feel your fibular head. The rest of the bone is encased in muscle until you get closer to the ankle,) makes up your anterior compartment.

We as triathletes will see this issue as just one of the "overuse" injuries that find themselves on a long list of potential issues to the 3 sport endurance athlete. That said, this can be an acute problem in some that needs to be addressed, "Before the sun goes down!" While the source of this urgent scenario can accompany a fracture or severe blow to the extemity, some develop it spontaneously with no prodrome what so ever. Others may already be in a cast or dressing which has been applied overly tight and needs to be loosened pronto.

Traditionally, the first signal that this may be occuring in the acute setting is pain out of proportion to the injury. The compartment can feel full or tight, firm to the touch. Some will complain of accompanying numbess or a burning feeling in the leg. However, the "chronic" picture is more one of pain in this location with exercise. With either, after a full check of the motor and nerve function of the limb, the examiner will try to elicit pain by passively stretching the muscles.

If the diagnosis of ACUTE compartment syndrome is made, the next step is to the operating room to "decompress" the offending compartment. The image above shows what's known as a fasciotomy, an incision (not excision) of the fascia to allow the contents of the compartment to expand. Ultimately, they will return to near pre injury size but the athlete will not suffer the ravages of untreated disease, in some cases, an amputation.

When CHRONIC compartment syndrome, exertional compartment syndrome, is considered in the diagnosis, the examiner will use the pressure measuring device in image 1 in the office, have you run for a pre determined interval, and again measure the pressure. Remember, this is frequently what's called a diagnosis of exclusion where one tries to rule out the other more common causes of pain in this area with plain xrays, etc. If conservative measures fail in the chronic case, the compartment may need to be released on an elective basis. But, you'd save surgery till last in most instances.

Images 1, 2, 3 Google images, #3 Elsevier

Sesamoids

2011-09-19T08:53:00.000-04:00

Although small, the sesamoid bones in your feet can lead to big problems!

His shirt says: It's just safer to sssume I know Karate

This is "Herbert" of Slowtwitch.com. If you're not familiar with him because you spend no time on Slowtwitch, that's a mistake. Give it a look when you have a free moment.
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"Give me three steps, gimme three steps mister..." Lynyrd Skynyrd

To the right is a pair of legs. "Old legs," you might quickly say. Yes, but old legs standing on the pier in Kona that have qualified for the race. Hmm, lookin' better all the time!

I field questions al the time from athletes with foot problems and a possible sesamoid fracture. Do I need a bone scan? Do I need surgery? Etc. It occurred to me that most folks didn't know they had sesamoid bones, or if they did, where they were.

The simplest definition of a sesamoid bone is one that's surrounded by tendon or intra-tendinous. The most obvious example would be the knee cap. This blog will be devoted to the pair of sesamoid bones underneath the ball joint of the big toe. They are about the size of a lima bean, normally glide front and back with each stride and rarely give us much cause for concern.

But as with any bone in the foot, they can be broken or subject to a stress fracture. A true fracture takes a pretty significant injury such as a fall from a height where we in the endurance sport world are more likely to see a stress fracture from the usual causes. The athlete with a true fracture is going to be immobilized between 4 and 8 weeks, will be made non-weight bearing on crutches, and likely be doing all of his/her training in the pool for a while. Treating the stress fracture is much less aggressive, but here, too, your running shoes will see no action for longer than you'd like. Note: like so many things displayed here, it is so much better to get this fixed right the first time and not be bullheaded while trying to train through it. You'll be so glad you did.

Often times, sesamoid problems present as sesamoiditis, an inflammation of the area caused by the usual culprits of too much too fast, especially speed work or hills. One starts with the gradual onset of pain under the big toe, initially present during only the hardest portion of the workout and increasing to any running, even walking. There doesn't seem to be much redness or bruising. They can be slightly swollen but frequently it's not easy to see.

So what do you do? Back off for a while. Maybe do a percentage of your weekly run volume in the pool. (It can be fun.) Then, if you can unload the area of distress by using a metatarsal pad or other device to very slightly overload the non-injured portion of the foot being certain to ice down the area once the run is over. Don't be so aggressive that you risk frostbite but 15-20 minutes ought to do it.

Lastly, trying to go through your log book examining each week, each run, for clues as to the cause and how to never have it again is always beneficial. And if you're successful, your "three steps" will be crossing the finish line without pain!

Image 3 Google images

Separated Shoulders

2011-09-11T19:58:00.000-04:00

"People say believe half of what you see, and none of what your hear." Marvin Gaye, I Heard It Through The Grape Vine

I'm not sure that's Marvin's always right. In this case, I'd believe all of what I see.

Difference Between Soreness and Injury

It’s normal toexperience some degree of pain while exercising and in the early recoveryperiod. Usually we’re talking musclesoreness from a good work out effort. Infact, the US Navy SEALs are fond of saying that, "If you complain of musclesoreness around our house, you’re just bragging!” However, if the athlete begins to have morespecific pain in a joint or a muscle group it’s probably time to back off abit. Time to reduce the load for a fewdays. (Better to take a pass on a full work out or two than to risk placing oneself inpotential peril.) If resolution of thepain is not seen, it may be time to seek help.

But, athlete after athlete ignores this recommended behavior. They are so driven, that it's more important to get the workout done...care and feeding of the log book you know...than to exercise simple, adult-like common sense, and an injury situation that could put them out of commission for and extended period time is risked. Please don't let this be you.

Separated Shoulders

The most commonly broken bone in the body is the clavicle. Before the development of a series of plates which conform to the natural contours of the bone, phrases like, "If both ends of the bone are in the same room it'll heal" were common place. This is close to the truth but not in every case. We as an Orthopedic community frequently settled for less than optimal appearance and function. The result was a shoulder with a shortened clavicle with a big, not terribly cosmetic, bump over it. The newer plates eliminate that, but then an operation is required to get them in and reduce the fracture. The plate generally stays in forever, and in most instances, will not set off the TSA alarm at the airport. Recent recipients of such a plate are Lance Armstrong and Frank Schleck. If I had a clavicle fracture I would give serious thought to using this device and recommend it be part of your treatment discussion should you unfortunately have the same.

Similar advances have been made in treatment of the separated shoulder. Simply speaking, these injuries occur after a significant fall striking the shoulder. The ligaments at the far end of the clavicle are torn to a degree, some worse than others, and in the more severe injuries, the end of the clavicle becomes quite prominent. There's a big bump over the end of the shoulder. Should this be the case, one of the recommended possibilities will likely be arthroscopic reconstruction of the joint, possibly using surgical hardware and/or tissue from the tissue and bone bank.

This is an important concept to understand as an occasional bad actor in the tissue harvesting arena gives the whole business a bad rep. As you know, we put all kinds of things in our bodies that used to belong to someone else. A good example is blood. I'm on a first name basis with the folks at the local blood bank as I donated my 100th unit of blood last year. Blood products are used in so many ways be it to help resussitate trauma patients to those with hemophilia. The same is true of other body parts needed for ACL reconstruction, eye surgery, total joint replacement, and in this case a reconstruction of the acromio-clavicular joint.

In the not too distant past, a number of large screws, braces, Gortex straps, etc. were designed to hold the joint in place and none worked very well. Currently, the use of small threaded screws, buttons and "allograft" (from another human) tendon tissue work quite nicely to restore the relationships of the A/C joint. After a period of early rehab, patients are returned to weight training about 3 months after the operation and sports requiring contact like lacrosse or football by 6 months. It's a good operation which seems to solve the problem and one that I feel will stand the test of time.

Right acromioclavicular separation.

4 weeks until Kona - good luck to all participating. Don't forget that warm weather acclimation is one of the big keys in this race.

Images 2, 3 Google Images

Joint Replacement in Triathletes

2011-08-28T20:28:00.000-04:00

"And I'll taste every moment and live it out loud,
I know this is the time, this is the time to be more than a
name, or face in the crowd, I know this is the time,
this is the time of my life." David Cook, American Idol

Been told you need to have a joint replacement?

Well, this will make a major change in your choices of sports. I talked with one of the companies that manufactures joint replacement products to see if there'd been any major changes in the recommendations for those who've undergone knee or hip replacement. I'm sad to report that there have not. Joint replacement is the end resort when a patient has unrelenting pain accompanying arthritis of a joint. The orthopedic community has improved the current artificial joints to where we now feel that they should last approximately 20 years depending on the age of the patient, weight, activity choices, etc. The operation is performed as an in-patient, under anesthesia, and a hospital stay of 2-3 days is common. Frequently you are encouraged to put all your weight on the operated limb from day 1. Potential complications include bleeding, blood clots, infection, surgical failure to name just a few.

Once fully healed, you will be encouraged to swim, bike, dance, stretch, etc. You may note that participation in triathlons is not found on the list and for good reason. One's goal is to get the joint to last as long as possible, potentially for the rest of your life. Re-operating on an artificial hip or knee is significantly harder than the initial procedure, the results less certain and the possibility of complication higher. That said, one recent study found that 80% of hip replacements in patients under 65 were still working well at 15 years while 94% of those over 65 had the same success. It's felt that risk factors that shorten the longevity of the prosthesis include weight, age as just noted with being under 65 a risk factor, choice of activities (even though some may not hurt they may over stress the new joint), avoiding complications like fracture around the prosthesis, infection, dislocation, etc.

When I earned my MBA before med school, in Marketing class we learned about early adopters, a sub group of folks who don't mind a little increased risk or expense if they can have the latest and greatest products around. Sound like anyone you know? Like most of the triathlon community? You bet. But, in this situation, it may be best to work carefully with your surgeon as the newest product that may be well intentioned, designed to last a lifetime in all, may not. One of these is called hip "resurfacing" in which less bone is removed and a cap placed over the head of the femur. It's specifically marketed to the younger patient. Floyd Landis had one in 2006.

Although we as physicians think we have the answers to longevity through research, one of the manufacturers is encouraging real world answers to patients who have one of their joints implanted. in other words, regardless what what they were advised to do, what have they really done and has it affected the joint wear? One example of this was a woman I saw on Slowtwitch, several years out from a hip replacement, who did iron distance racing. Or a gent I met in my first Ironman in 1982 with a total knee replacement who'd suffered a gunshot wound to the knee as a serviceman in Vietnam. These folks and others like them will continue to contribute to joint replacement research, hopefully with success galore.

Images 2, 3 Google Images

ACL Tears, Should I Fix Mine?

2011-08-21T20:51:00.000-04:00

"I always wanted to be somebody, but now I realize I should have been more specific." Lilly Tomlin

ACL Tears 2011

My last blog from a couple days ago discussed "what it you need surgery?" This is the next step in that discussion.

It wasn't that long ago that the triathlete who tore his/her Anterior Cruciate Ligament had suffered a career ending injury. But, over the last 30 years, particularly the last 10, we as an Orthopedic Community have improved both our understand of the structure, location and function of the normal ACL as well as it's reconstruction.

As seen in the images above, the normal ACL spans the knee joint between the femur and the tibia. It is a stout structure which limits the forward travel of the tibia under the femur as well as playing a role in rotational stability. While seldom injured when a blow occurs to the limb, they will rupture when a twisting force, like falling off a bike or slipping on a wet pool deck, is applied across the joint. When this happens, the knee fills with blood and it's normal stability pattern is frequently lost. A torn ligament is not repairable.

Now What? An ACL reconstruction is a pretty big operation with a sizable rehab commitment that nor everyone can or wants to follow. In the not too distant past, it was reserved for high performance athletes but the above noted improvements have lent this operation to older (and younger) patients. The physicians in the Arthroscopy Association of North America when recently polled "recommend reconstruction in 98% of their patients." The old adage of not having this operation between "3 days to 3 weeks" post injury seems to hold true in many.

Like many knee operations done today, this one is done pretty much arthroscopically but that's where the similarity ends. To reconstruct a torn ligament one needs something to put in it's place. This can be something from you or possibly another source such as the the local tissue bank. The two most common options from your own knee include a small portion of your hamstring tendons or the middle third of your patella tendon. When using a tissue bank and donor tissue, the choices are virtually limitless. Examples would include hamstring or patella tendon, Achilles tendon etc. Which of these is ultimately utilized is up to the patient and surgeon, and at one time or another I've used all 5 sources.

Once that decision is made, and the pre-op amenities taken care of, you'll find yourself at the surgicenter discussing choices of anesthesia with the anesthesiologist. Listen carefully and choose which method seems best for you. It will not make a difference to the surgeon. Depending on what needs to be done to your knee the procedure will take 1.5 to about 2.5 hours and you'll wake up in the recovery room, frequently with a brace on your leg and a device circulating ice cold water around your knee to help with pain control. Once you're fully awake, the pain is under control and you feel like it, they'll let you go home...new ACL and all! You'll undergo pretty detailed physical therapy in the coming months and likely miss the rest of the racing season but you've just made an investment in your future and can kick butt next season.

Image #2 Google Images, 3# Bryce Groark

Surgery, What If I Need It? Plus, Winning Transitions

2011-08-17T17:29:00.000-04:00

He who will not risk will not win.”

John Paul Jones

"You’re going to need an operation."

Now what?

“And then he walked out of the room.” If you’ve never had surgery, being told that the next step in your care involves a trip to the operating room can be a tad upsetting. What’s going to happen to me? How long will it take to get over it? Can I pay for it? Are you sure there isn’t another way to get better?

These and a 1000 other questions run through the mind of the new patient as he/she’s been told, for example, that their shoulder will continue to dislocate unless something is done surgically to prevent it. Although it seems difficult, maintaining control is important and having some idea of what questions you need the answers to helps. In this setting, our shoulder dislocator will probably have a discussion with the surgeon about the procedure, basics of the reconstruction including risks, location of the incision, time in hospital if any, post op therapy and finally return to sport.

There will also be a discussion with the nurse/assistant covering the nitty gritty details like agreeing on a date for the operation, where and time, diet, what to wear, pre-op blood or lab work if needed, and all the little details that are so important to the patient. In our office this often includes a video about the surgicenter, parking, and an example of someone else going through the same basic surgery to try to put them at ease. Also at this stage is the first of several permits that you’ll be asked to sign, the permit for surgery. In our exceptionally litigious society this is the first document that you’ll see explaining the basic nature of what will happen to you and the basic risks. You’re giving the surgeon permission to do the operation understanding that positive results, while implied and hoped for, are not guaranteed. If you have any doubts, want a second or even third opinion, now’s the time to do so! You’re the one having the operation and need to feel not only is it right for you but that this surgeon and medical team are also right for you. It doesn’t bother the surgeon at all if you say you need to delay the procedure, ask around, and in fact some docs actually encourage it. There are some operations that get better results early, (when not delayed) however.

You’ll also probably talk with the insurance office. On the day of surgery you’ll arrive at the hospital/surgicenter an hour or two early, change into one of those funny gowns that opens in the back, meet the anesthesiologist - another permit – and discuss the options for anesthesia, picking what’s right for you. There may be an IV involved also. And when your turn comes, off you go into a whole new world.

Good luck!

“I always win the transitions!” says a patient of mine. And he does. I think he feels that more important than the race results.

Here’s how. He makes things very simple. 1) only bring into the transition area what you absolutely need, 2) Practice, practice, it’s all in the set up, and 3) Keep it simple.

The day before the race, know the course cold. It’s so easy to memorize. On race morning when you rack your bike and drop your stuff do a nice slow walk through from your bike to the mount line and from the swim exit to your bike. Do it a couple times (not talking to your friends but to memorize it.) it will also help you relax some.

Anyone can have a lightning quick wetsuit exit. If you ever have the pleasure of volunteering at the transition area of a sprint tri, watching the comedies of wetsuit removal appears not unlike Harry Houdini and his 1920 straight jacket act or the wrestling of an invisible opponent. First, Training Bible Coach Jim Vance will tell you to cut off the bottom hands breadth of the legs off the suit. "I guarantee you it will make no difference in your swim" he says, you’ll just get your feet out faster. And PAM sprayed around the ankles will make this remarkably easier. (Just make sure you use regular PAM as the flavored types seem to attract hornets, as one triathlete found out the hard way.) As you exit the water, you’ve unzipped the suit – while moving, you’re always moving – and a shrug or two aids in getting the top down to your waist giving you the appearance of the so-called “headless monkey.” At your bike, a quick pull gets the suit to your knees and Coach Eric Sorenson of the Annapolis Striders would tell you to simply step on the suit and pull your foot out http://www.youtube.com/watch?v=brHcsqKM_mo . All this in under 10 seconds. Remember that pre-race practice stuff? Your race number is on a belt under your wetsuit so it’s helmet, sunglasses and go! Forget that toweling off and foot bath stuff – unless it’s part of a pedicure. Really, you won’t blister in a sprint race.

That your bike shoes are already clicked in and fixed to the pedals with rubber bands, left pedal forward assuming you mount from the left, is a given. This has been shown time and again to be the quickest. If, during your home transition practice before the race, you ride barefoot with your feet atop the shoes for 5 or 10 minutes you’ll see how easy it is giving you one more learned skill that may be important one day. In the race, you’ll have a quick mount well away from the start line and other riders. The mount line has the highest potential for collisions that might ruin your day. When you return to T2, slip on those lace locked running shoes, grab your hat and you’re off. Some cannot do this standing up and will duct tape a towel to the outside bottom of a plastic milk crate, place it right next to one’s front wheel, and use it as a quick seat to apply running shoes. It also makes for a handy way to transport your gear in/out of the transition area.

Compare your transition times to those in your age group, and to your performance last year and YOU WILL BE THE QUICKEST!!

And remember, SUPPORT THE SPONSORS THAT SUPPORT YOUR RACE. It wouldn’t be bad taste to also wear their logo.

Not Yet Ready For The Glue Factory

2011-08-15T09:25:00.000-04:00

"When prescribing one of the drugs I take, my doctor warned me of a common side effect: exaggerated, intensely vivid dreams. To be honest, I've never really noticed the difference. I've always dreamt big."
Michael J. Fox

T-shirt in Hawaii

This is the time of year when a select few of the triathlon dreamers are paid off. It's almost KONA TIME. I haven't missed one in years and my biggest reward is helping the first timers by working many hours on the pier to make sure that it's perfect for those racing. I just love it.

But many of us have dreamed for years only to have those wishes squelched by reality. Too old, too slow, too everything. And in those criticisms chimes in injury, pain, aging, etc. causing many among us to bring their racing career to an end. Or, they at least modify it trading distance events for sprints and what not. And I think that's just fine. Normal. The way things should be and not something to either bring on regret or be embarrassed about.

Post race: Note red slash through the number - a penalty, likely drafting.

When is it time to call off the dogs?

Jim is a 42 year old triathlete who e-mailed me recently after his third knee operation. A high school football player, he'd torn one of his knee ligaments, undergone successful reconstruction, and played his senior year. But it cost him nearly a year of no sports. Fifteen years later, without much trauma, he'd needed arthroscopy to remedy recurrent swelling. A "touch or arthritis was found," he says. He gravitated away from pure running to triathlon to "give my knee a break" and really took to the sport.

Well, he got a decade out of the knee as long as he overloaded swim and bike training keeping running to an absolute minimum. Now, even that doesn't work. He's had another "clean up" operation and the arthritis is worse. he's only 42! So, what advice do you give to Jim? Have a knee replacement and quit yer bitchin'? Not hardly. Or, the tri forum answer for all questions from pain to finance to marital discord, your seat's too high? (Just kidding.)

Seriously, we will all face the day when we are forced to ask ourselves, "Do I need to back away from triathlon? It's usually not the best of days but does require honesty. And we as triathletes are not good at that when it comes to self-knowledge. It's a process and will probably occur spontaneously over the course of several years.

One athlete I know had his "moment" at mile 20 on the marathon in Kona about 6 years ago. He was walking. He'd been walking. His feet hurt, his back hurt, he was dead tired, and just like the Truman Show where everyone is watching you, he felt everyone along the course was watching him perform at a level far below his best. "It hit me in the head. I thought 'What am I doing here?' Obviously, iron distance racing is no longer the way I validate myself. I don't have to do this anymore."

Whether it's injury, family or job needs, expense, the absolute refusal to spend so large a part of every day dedicated to self interest, my training, etc., at one point we'll all make the decision to stop, or at least reduce the triathlon burden in our lives. And it will be just fine. Trust me, I've been there done that, and life on this side is just fine. Heck, I can drink beer whenever I want now. You?

There's no shade on the Queen "K" highway.

"We're all pretty bizarre, I mean some of us are just a little better at hiding it, that's all."

                                                                                            The Breakfast Club

I'm ending with this quote to remind each of us to keep the role of triathlon in perspective.  For some it's a life long pursuit at a high level, best of the best, but for most this isn't true. Take from triathlon what it will give you, give back what you can,and when it's time, cast off for a new adventure. Life is what you make it.

And always say thank you to the volunteers!

Mid/End of Season Injury Self Eval

2011-08-13T17:21:00.000-04:00

Despite recent shoulder surgery, this triathlete is still volunteering.

"You want to be famous? Learn how to take blood out of car upholstery?
John Travolta, Hairspray

This is the time of year for goal review, for updating planning, and determining if the path we're walking (our 2011 training plan) and see if they have lead to success, limping...or both!

Consider that, according to a piece in the British Journal of Sports Medicine a couple years ago the ten most common overuse injuries that are seen in the running population are:

1. Patellofemoral pain (21%)
2. ITB Friction Syndrome (11%)
3. Plantar Faciitis (10%)
4 Meniscal Injuries (6%)
5. Shin Splints (6%)
6. Patellar Tendinitis (6%)
7. Achilles Tendiniitis (6%)
8. Gluteus Medius Injuries (4%)
9. Tibia Stress Fractures (4%)
10.Spine Injuries (3%)

Note that the key word here is OVERUSE. Since this is only early August, this is a golden opportunity to potentially revise one's schedule for the training and the remainder of the racing season. Adam Zucco, Age Group winner at IM California 70.3 both of the last two years, and Training Bible Coach would have his coached athletes list their planned races for the upcoming season and the importance of each. Using the periodization model, he'd set up a 3 weeks on/1 week rest repeating game plan to slowly build, first the mileage, then the intensity (accompanied by a decrease in volume). In other words, he understands the principle of gradually increased load that the body will respond to rather than acute increases in training stress. This will give the racer the highest likelihood of both improving the level of fitness but doing so with the lowest potential for injury. While this is not new thinking, getting it right can be a chore.

As you revise your plan, remember that frequently runners will come in to the clinic and have a single work out that pushed them over the brink. Oftentimes this was something foolish like racing against a friend, pushing thru pain when they knew they should stop and walk, beer miles,etc., that will cost them a part of the season, and, as they used to say in the U.S. Army commercials, the opportunity to "Be All You Can Be." The time to start thinking was yesterday.

Hey lady, did you know there's a bird....

Foot Surgery (Cosmetic Foot Surgery), Do You Really Need it?

2011-08-04T21:55:00.000-04:00

" I have given a name to my pain. It is Batman."

Jack Nicholson, The Joker, Batman

“If more people ran,fewer would be dying of degenerative heart disease, sudden cardiac arrest,hypertension, blocked arteries, diabetes and most other deadly ailments of thewestern world.”

Born toRun

While there may be some minormedical inaccuracies, the sentiment rings true.

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Triathlon Lifestyle

As triathletes, our lifestylemay seem a bit odd to some outside the sport. When noticed, some athletes use it as an opportunity for self-promotion,“Ain’t I grand…..why, yes, those are compression hose under my businesssuit…how did you ever notice?” But formost of us, the life choices are about fitting our training in around theschedules of others without being too much of a bother. And, if they stick out a little, having madea commitment to health, so be it. Michael J. Fox may have said it best noting, “What other people think ofme is not my concern.” I know onetriathlete who makes a habit of doing for others, particularly at work, and thefact that she rides her bike to work…occasionally having stopped by the poolfor a couple thousand yards first, makes her all the more valued as an employeewho contributes to the bottom line.

“Cosmetic” Foot surgery

For those of you who might be concerned about the appearanceof your feet, some would be motivated to seek out a professional who couldperform an operation to perhaps “normalize” them. Others might see an inability to wear aparticular type of shoe be it for athletics or fashion and wonder if surgerymight be the answer.

There may have been a time when some would tout the benefitsof a “30 minute procedure” in someone to prevent the development of a bunion,straighten a painless toe that’s a little crooked or even augment the fat padfound on the sole of the foot to accommodate high fashion foot wear, etc. But those days are gone. Both the American Orthopedic Foot and AnkleSociety and the American Podiatric Medical Association have put out a positionstatement to the effect that,

"…foot surgery not be performedsimply to improve the appearance of the foot. Surgery should never be performed in the absence of pain, functionallimitation or reduced quality of life.”

v ….yetthere are many proponents in the field who argue that the procedures are safeand justified. But, consider therisk. In addition to the usual bleeding,nerve damage, surgical failure, etc. one faces the potential of recurrentdeformity or development of life long big toe arthritis. In fact, formany of these complications a successful revision procedure is not available! In short, it may not allow them to wear more attractive shoes and may put them atrisk for a lifetime of chronic foot pain.

So the take home lesson here is that while foot surgery, orany kind for surgery for that matter, may be occasionally indicated, theeducated patient who’s aware of alternatives and the potential for problems islikely the one who’ll get the best result.

Image 2, Google Images

Bursitis Hip, Knee and Elbow

2011-07-31T20:30:00.000-04:00

"....you can't always get what you want.
But if you try sometimes,
you might find, you get what you need."

Rolling Stones

I've heard that the following was a serious question; "Was Paul McCartney in a band before Wings?"

I 'm afraid, as it's it's been pointed out many times, that those of us who do not understand the past are doomed to repeat it. With respect to injury, triathletes continually repeat the errors/oversights of those who've raced before us. With the same poor results and lost time training I might add.
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Now that we're smack dab in the middle of the summer, and more and more of us are at the peak of our training year, there will likely be a commensurate increase in sore, aching limbs. It will be pretty tempting to ignore these "minor aches and pains" or treat them with a little I'm an Ironman liniment, but a wiser choice might be to pause and seek out the cause of this distress. Is this pain secondary to bursitis or an inflammation of the fluid filled sacs (bursal sacs) that surround or cushion our joints?

Bursitis is a condition that causes these sacs to become irritated or infected heralding pain associated with motion. If this is diagnosed as infection, prompt intervention by the medical team is important to keep the process localized and (hopefully) minimize it's severity. As noted in this blog two weeks ago, the patient presenting with joint pain, say an elbow for example, has the potential for this to be arthritic, tendinitis, stress fracture, etc. and the care giver must differentiate between these entities. If the working diagnosis is bursitis, culling out the infected from non-infected is the next step. We've previously noted that bursitis of the heel is predominantly an overuse type issue as is the hip. When considering the knee and elbow, so-called pre-patella bursitis and olecranon bursitis, we generally think of a chronic or low level of trauma keeping the potential for infection on the table.

Symptoms of bursitis might include pain in the vicinity of the joint, an actual swelling of merely a sense of fullness, warmth, and/or redness. In the hip this is called trochanteric bursitis and is usually found over the bump on the outside of the hip frequently radiating to the thigh. It's worsened by laying on that side, stairs, or upon standing from the seated position. The elbow will demonstrate a fluid collection over "the point of the elbow," frequently involving infection.

In the knee, this has picked up the term "housemaids knee" and occurs after prolonged kneeling, previous injections, kidney disease, etc. One can actually see the swelling as a pocket or pouch over the front of the knee. Infection is part of the suspected diagnosis.

Treatment of bursitis usually does not involve surgery and can include compressive dressings and ice, changing ones activity to avoid/lessen the offending stimulus, aspiration and culture to determine presence/absence of infection - primarily in the knee and elbow. Those determined free of infection may occasionally be candidates for a corticosteroid injection. That said, if steroids are administered to one that's infected matters can be made much worse! NSAIDS and antibiotics will commonly be part of the plan.

In short, as in many problems presented in this blog, early diagnosis and treatment with careful follow up give the highest probability for success and return to the age group wars!

Images 2 and 3, Google images.

Fluid Management, Work Out Guilt

2011-07-21T16:42:00.000-04:00

Feel guilty when you miss a work out? Does a situation like this sound familiar? Your airline cancels your flight home and you're forced to get a rent-a-car for your final leg. You finally walk in the front door at 4 am, beat. Now what? Should I can my morning work out?

This decision, or one like it, is one we constantly face through out the season. Being mentally prepared before it occurs will make it less of a physical (or psychological) negative. As noted in these pages before, the sport of triathlon attracts those who thrive on consistency. An addictive behavior of sorts. And, when that behavior - the work out - is accomplished early in the day, we're relaxed, sharing, fairly normal individuals. But, upset that apple cart with travel, a vacation, an unexpected meeting, etc. and the "addict who misses his/her 'fix' " surfaces. Although it's obvious, the season doesn't hinge on one work out, one day, or even one week. If this can burned into one's brain early in a tri career, your family and workmates will be better for it...and so will you.

I thought he'd be done by now.

Remember that we're also part of a family team and their thoughts, needs and priorities need to be part of the equation.

A comment on fluid management appropriate for July. "Plus the air is so dry that by the time you feel thirsty, you could be as good as dead; sweat is sucked so quickly from your body, you can be dangerously dehydrated before it even registers in your throat. Try to conserve water, and you could be a dead man walking." Born to Run, Chris McDougall Although he's describing running in Mexico's heat, the message should be clear. A local high school runner died a few years ago in the heat - plan your runs, don't neglect re hydration, and if you can avoid the heat of the day, all the better.

It's said that some years the road surface temps exceed 120 degrees. As you might expect, there are differing perspectives on the best way to maintain fluid balance and each of us needs to understand what works best for us as individuals. The best strategy for your training partner might or might not work for you. Some advocate directing fluid intake by thirst, some by schedule, and others a plan - like your nutrition plan - that's been worked out by you during pre-race training.

I happen to be in the latter camp. I believe that it's just "cake" to keep track of your fluid intake, type and volume, during your long rides/runs...and then importantly the next several hours, to determine your specific race needs. Keeping track of the temperature and relating this to the temperature on race day is also helpful. This is not to say that you won't get dehydrated during the actual race. You will. But there's a point beyond which our performance diminishes as you well know and if we can skirt that level, we win. In short, you plan everything else before a race, in my opinion, fluids get planned as well. But only after practice, practice in the pre-race setting. (Personal Note: although my iron distance career is complete, one of the best days of my year every year is working as a volunteer athlete escort in Kona. After bike inspection, the athletes need to rack their bikes and transition bags and understand the intricacies of transition entry and exit. I try to get only first timers, walk them through this whole process, and visualize their whole experience on the pier. Where/how do you come out of the water here? Exactly what route do you take? Have you reviewed flat tire repair recently? How do you plan to handle the heat and fluid needs? And 100 other questions so that when they walk off the pier, unknowns have been changed to knowns. There's enough to worry about on race day. If I can make their day a little smoother - good deal.)

2 mile mark on Hawaii bike course. (Not everything is cake, though.)

Bursitis, You Probably Don't Need Surgery; Is Stretching of Value?

2011-07-09T21:13:00.000-04:00

At your local bike shop soon, avoid the Christmas rush!

Mt. Whitney Calls - I'll be away for the next ten days as my two sons as I head to California's beautiful Sequoia National Park to hike the High Sierra and John Muir Trails and then summit Mt. Whitney. At 14,505 feet it stands as the tallest peak in the lower 48 states. So rather than swim, bike, run, write.....it'll be hike, hike, hike!
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A recent triathlete's letter asked for help with his "heel bursitis" only I wasn't sure that was a correct diagnosis. This is an exceptionally common scenario for so many who get their medical care from Internet chat rooms. Heel pain for example is, to some, plantar faciitis, because it's the only diagnosis they know. In fact the heel can be a very busy place and just a couple of the diagnoses that spring to mind could include:

1) Posterior tibial tendon problems
2) Tendonitis of either the peroneus longus or brevis
3) Achilles tendon rupture, partial tear or tendinitis
4) Stress fracture of the calcaneus (heel bone)
5) Fat pad atrophy
6) Infection or tumor
7) Tarsal tunnel syndrome
8) Plantar faciitis
9) And, oh yeah, bursitis. But is it the retroachilles bursa, retrocalcaneal bursa, etc.

My point here is that so often the questioner has only a vague suggestion of accuracy in his/her diagnosis and without a specific explanation of the source of the problem, how are they ever going to improve? Yours odds are improved by a thorough history and physical, and occasionally some medical tests may be needed to help the medical team identify bursitis and determine whether or not infection is involved.

So, today we'll cover heel bursitis and save bursitis of the knee, hip and elbow for another time.

Heel bursitis, or in this case more accurately retrocalcaneal bursitis occurs between the back of the heel bone and the front of the Achilles tendon. Much less frequently we find problems with the subcutaneous calcaneal bursa seen above or the retroachilles bursa (didn't expect it to be so confusing did you?) but today we'll stick with the former. The bursa acts to decrease friction in the area where two structures move in different directions. Bursitis then is inflammation of the bursa, diminishing it's ability to slide, making it more and more irritated when it's moved.

The cause is multi factorial from repetitive motion or excessive pressure to poorly fitted foot wear that is overly stiff and repeatedly compresses the Achilles insertion. There can be coexistent Achilles tendinitis and the examiner will check for a Haglund's deformity - a spur on the back of the calcaneus. Less commonly it will follow trauma such as a bike crash or fall. In any event, the triathlete will show a red, painful heel which is quite tender when pressure is applied.

Conservative care is the norm with an ice pack and some type of compression dressing including a significant reduction in the offending activity (training) and often the use of a NSAID like ibuprofen. Many will recommend both a stretching program along with a careful footwear evaluation. And, even though it's uncommon, infection does occur here and careful follow up is in order.
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This was recently posted on www.aaos.org, the web site for Orthopedic surgeons and I found it of interest. I hope you do as well.

02/17/2011
Stretching Before a Run Does Not Prevent InjuryHowever, runners who typically stretch should continue, or risk injury
San Diego, CA
Stretching before a run neither prevents nor causes injury, according to a study presented today at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).
More than 70 million people worldwide run recreationally or competitively, and recently there has been controversy regarding whether runners should stretch before running, or not at all. This study included 2,729 runners who run 10 or more miles per week. Of these runners, 1,366 were randomized to a stretch group, and 1,363 were randomized to a non-stretch group before running. Runners in the stretch group stretched their quadriceps, hamstrings, and gastrocnemius/soleus muscle groups. The entire routine took 3 to 5 minutes and was performed immediately before running.
The study found that stretching before running neither prevents nor causes injury. In fact, the most significant risk factors for injury included the following:

history of chronic injury or injury in the past four months;

higher body mass index (BMI); and

switching pre-run stretching routines (runners who normally stretch stopping and those who did stretch starting to stretch before running).

“But, the more mileage run or the heavier and older the runner was, the more likely he or she was likely to get injured,”
“As a runner myself, I thought stretching before a run would help to prevent injury,” said Daniel Pereles, MD, study author and orthopaedic surgeon from Montgomery Orthopedics outside Washington, DC. “However, we found that the risk for injury was the same for men and women, whether or not they were high or low mileage runners, and across all age groups. But, the more mileage run or the heavier and older the runner was, the more likely he or she was likely to get injured, and previous injury within four months predisposed to even further injury,” he added.
Runners who typically stretch as part of their pre
The most common injuries sustained were groin pulls, foot/ankle injuries, and knee injuries. There was no significant difference in injury rates between the runners who stretched and the runners who didn’t for any specific injury location or diagnosis.

Image #2, Google images

Arthritis in a "Former Triathlete" - Surgery Upcoming?

2011-07-05T21:28:00.000-04:00

A question that comes up all too often is the athlete who wants to compete but due to a medical condition beyond his or her control they find themselves to be "former triathletes." I've always found this to be a troubling definition as the person is, in one sense, is allowing themselves to be defined by a sport when they have so much else to offer. I suppose we're all former somethings but just like Julie Andrews says in Sound of Music, "When the Lord closes a door, he opens a window somewhere." I firmly believe that when confronted with a situation like this, opportunity is knocking somewhere else in your life and that before too long, you'll open the door where this knocking occurs.

The following is a letter I received today that may reflect this approach to life:
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I'm a 51 yo former triathlete who can no longer run due to an arthritic knee that is "bone on bone." I had my last of 3 surgeries in May 2011 and have not been able to run more than 3 miles without increase in pain. This is after a series of 5 sinvisc (sp) shots. They lasted 3 months , but after that back to the pain. I currently swim 15k a week and ride 6 hours w/o too much discomfort save for a hilly , hard ride, then it starts to hurt. The next step is partial or full knee replacement. Can you tell me if there is a chance of running after such a surgery and is there a criteria/series of questions to help a patient decide to have knee replacement? Thank you for your blog, Chris

This is a slight modification of my response.

Chris - this is a big problem that faces many triathletes. As you scan the number of entrants in each age group at your local triathlon, as we age the number of folks in each older group is less than the one preceding. And you know that there are a bunch of former triathletes (like you) who'd like nothing better than to be at the starting line but can't because of arthritis such is present in your knee or some other medical issue.

I'm sitting at the airport having just taught an Orthopedic course to a couple hundred primary care docs this morning and this is what we discussed. Arthritis of the knee comes in many flavors. Some have worn through the cartilage over a wide area while others have a smaller lesion surrounded by normal tissue. It sounds like you're in the former category and replacement, if it's just killing you, may be a surgical option. But, at 51, if you can modify your activities such that you can put off any kind of surgery as long as possible, that might be the best path. If you have such pain that the above is not an option, the partial replacement, Unicondylar Knee Arthroplasty, is a good option if your disease is predominantly over only half of the knee. It's a smaller operation than a replacement, no ligaments are cut and motion down the road tends to be better. I like it.

As far as running after either procedure, I don't think you'd find a manufacturer that would support it. In the global picture, you want whatever is done to last the rest of your life, if possible, and if you have a lot of life left, you'd want this to survive as long as possible before you undergo surgery again. Golf, doubles tennis, light aerobics, hiking, etc. are all on the recommended list. Running is not. In short, if my brother had a UKA, I would encourage him to be a biker-swimmer-hiker, etc. but to wear his running shoes when he cuts the grass. I suspect that your best advice will come from your surgeon who knows your knee better than any of us. And, while you may on one hand be a former triathlete, I'll bet you're a present something else that will ultimately be even better. It's only a sport and you're so much more than a sport. We're pulling for you. Good luck!

From Michael J. Fox - "It may seem hard to believe, but it's catastrophe that offers the most promise for an even richer life."

Image #3, Google images

Surgery, What if You Need It?

2011-07-02T21:26:00.001-04:00

"Standing on a corner in Winslow, Arizona, such a fine sight to see. It's a girl my Lord in a flat bed Ford slowing down to take a look at me."
The Eagles

The Triathlete Mindset?

The Girls getting ready for Dad's Ironman finish.

Appreciate Summer: You're out the door at 5:15 am for that morning work out, no gloves, no tights, no coat, and you hardly need a flashlight if you need one at all. The same is true for the sunlight lasting well into the evening. It's pretty easy to get caught up in this and stay out past the time that you have lights and reflectors for. Be prepared. And, oh yeah, tell somebody your approximate intended route....just in case....you'll be glad you did.

ACL tidbit: A follow up comment on whether or not, if you tore your ACL, would your orthopedist recommend reconstruction. In a recent survey of the membership of the Arthroscopy Association of North America, when considering the young, competitive athlete, 98% of these docs recommend the procedure. 76% will generally perform a reconstruction on the 35 year old recreational athlete but when that athlete gets to reach 50 and has been out of triathlon for a while but still runs three times a week, the number drops to 35% recommending acute surgery. Stay tuned.

Surgery, What if You Need It?
Not long ago I received a letter from a triathlete facing the potential of surgery and she wanted to do "Anything to avoid it." I explained to her that in some cases, the shortest distance between you and competing at full strength may be a surgical procedure and that so-called conservative treatment will only delay the inevitable.

In the 1982 publication, The Complete Triathlon, the author notes "Too Many Surgeons - Too Much Surgery!" It's a charming text complete with blank pages in the back for "Triathlete Autographs." So, the rub against surgery is not new. Unfortunately, the author advocates things like Chelation Therapy for coronary artery disease (atherosclerosis), a "non-standard therapy" in which the patient is administered an agent frequent used in heavy metal poisoning, mercury, zinc, lead. etc. but "The American Heart Association states that there is 'no scientific evidence to demonstrate any benefit from this form of therapy.'" So, you're back to the potential for surgery.

Surgery has progressed enormously in the past few decades. Heck, we don't use near the number of leaches that we used to. For example, if you're told you have torn cartilage in you knee and athroscopy has been recommended, the surgeon is suggesting placing a 4mm fiber optic scope in the knee to first confirm the diagnosis, and then with other equally small incisions, put tiny instruments into the joint to fix what's found. The inside of the joint is usually photographed and, in my practice at least, we give the photos to the patient. Good for Christmas cards and the like. Plus it makes the patient feel that they have some sense of control.

These procedures are frequently not performed under generalanesthesia and the patient can watch the operation on the same TV the surgeonuses in real time. If you're undergoing a more complex procedure such as ACLreconstruction, rotator cuff repair of the shoulder, this may not be true. Thescope can successfully treat problems in the knee, shoulder, wrist, hip, ankle,and elbow. Although surgery done this way not requiring a formal incision canhave a shorter rehab, the specifics of this would be best left to your medicalteam.

Each type of surgery has it's own risks and rewards and each of us would do well to understand both thoroughly before signing on the dotted line.

Image #2, Google Images

EPO, Worth the Risk? Separate Lab Values for Athletes?

2011-06-30T20:06:00.002-04:00

"Make friends with pain and you'll never be alone."

Ken Chlouber, Creator of the the Leadville Trail 100
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EPO. Ever used it? Think it will make you faster? Increase your hemoglobin/hematocrit, oxygen carrying capacity, that sort of thing? As you might imagine, I get a lot of letters with medical questions. One recent questioner's note deserves discussion as, when discussing his own blood level, he stated, "I have a hematocrit of 51. I think it's normal, I looked it up." I politely disagreed.

I was told recently that I would be amazed at the number of age groupers who'd experimented with some kind of performance enhancing agent be it EPO (erythropoitin alpha), Adderall (the combination of dextroamphetamine and amphetamine used in attention deficit hyperactivity disorder), or any of the steroid or growth hormone products that we see pro athletes accused of on a routine basis. I couldn't believe it and still have a hard time comprehending it now. How could winning a fifty cent medal, competing for the most part against a group of people you don't know, be so important that you don't give it the same thoughtful consideration you do for your kid's school issues or the interest rate on your home mortgage?

Just to be clear, EPO (Epogen) is normally produced by the body in the kidneys and it stimulates the bone marrow to produce more of the oxygen carrying red blood cells. It's one of the agents that pro cyclists are accused of injecting to increase their gross number of red cells, their hematocrit. There are a number of problems with this:

EPO increases the rate of DVT, blood clots in the legs, which can break off, travel up the venous system to the heart/lungs leading to an increased risk of death . The primary docs liken it to sludging when the blood actually thickens.*
Patients given EPO as part of their treatment are at "Greater risk for death and serious cardiovascular events...to target higher versus lower hemoglobin levels....in two studies." In other words, we as athletes would be at a higher level of risk than patients with a lower blood count.*
EPO "...shortened overall survival...in some clinical studies..."*

In short, it just doesn't make any sense for one of us to take this drug. Perhaps the best we can hope for is the highest blood level that our bodies can manufacture without being pushed. Ensure that you get enough iron in your diet, not always easy for our meatless friends. Keep going to the blood bank to donate blood in the off season as not only are you helping others but it's been shown that the body will make just a little more blood than it needs to - sort of like natural blood doping. A rebound phenomenon.

Short History Lesson 30 years ago there was very little regulation of transfusions. For example, if you'd recently undergone a CABG (coronary artery bypass) your surgeon could give you blood anytime he/she felt like it. Then along came AIDS and the playing field changed. Limitations were placed on transfusions where, unless you had a documented hematocrit below 33, you were not permitted to transfuse the patient, even if the patient had pre-donated their own blood. Sometime later the level was dropped to 31, then 29, etc., all with the intent to only give patients what they absolutely needed.

This takes us to laboratory values. At our hospital, the normal range of hematocrits is 35 - 47. But, everyone of you who've donated blood, or had a significant bleeding episode of one cause or another, and then gone out on Sunday with the usual bike group, knows that you are sucking wind big time when it comes to climbing! It's said that losing one unit of blood, approximately 10% of your blood volume, only drops the hematocrit by 3-4 points. But it makes a difference for sure. You can still be in the normal range but have very abnormal performance.

But, is this true of all lab values? Should we as athletes have different normals simply because we're athletes? A piece in one of the tri mags presented that opinion recently. That as endurance athletes we have different normals than the gal next door. But I was unable to find support for that position after interviewing the head of Pathology of our hospital (in charge of all the blood tests, urine specimens, path reports, etc.) nor from Pathology of the University Teaching Hospital. I looked in my copy of the running bible The Lore of Running by Tim Noakes and was not able to find mention of a difference. For example, if the standards for serum sodium are 135 - 145, would an endurance athlete be higher or lower and how do you define endurance athlete? One who does sprints but trains a great deal? The Iron jock who may work out less but chooses a greater racing target?

The answer I was given by the Pathologist, a terrific biker who does the local hilly century ride in under 5 hours? Normal is normal.

* Physicians Desk Reference

Previous Knee Injury, Now Discovered Triathlon and......

2011-06-26T12:05:00.000-04:00

"I had some dreams, but they were clouds in my coffee."

Carly Simon

Summer Solstice: The triathletes dream day. The most sunshine, warmth, unlimited training . The only thing that could make it better would be if it were weekend day.
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I've done two recent blogs on knee injuries and this is pretty typical of the query I've received in response. Maybe this is you!

I tore my ACL and meniscus 20 years ago now and have had it repaired,
along with further keyhole surgery to clean out cartilage etc. Up until
a year ago I played a lot of competitive tennis and stayed away from
contact sports. Triathlon has become a bit of a salvation in last year
because it takes me away from so much lateral movement. However I am
approaching my running very tentatively and have not really improved by
10km race time by much during last season .......The question I have is can you recommend a book for running that caters
to someone like me i.e. history of a dodgy knee, working hard to
strengthen, very ambitious to make some great 10km times next season (and
hopefully run an IM at some point in the future,but needs to get the volume and
intensity of work just right, so as not to overdo it?

Hi George - I'm John Post, MD, Medical Director of Training Bible and Joe's forwarded your question on to me. I'm an Orthopedic Surgeon by trade and have reconstructed 100's of ACL tears and think I can help you with this issue.

First off, two of my last Training Bible blogs have been about ACL tears so your timing couldn't be better. Check 'em out. Also, I've gotten a couple other questions like yours so, using you as the good example, I'll try to share this in my next blog. In short, when people tear and ACL, or ACL and a meniscus, even if repaired by the best surgeon in the land, the knee is never quite normal. In other words, even though these two structures received surgical attention following your injury, you can bet that there's a significant probability that other ligaments in the knee were slightly stretched, or the joint lining articular cartilage had some measure of compression or shear damage as well. We currently quote patients 25 years, "and that's when you may start having problems" but this number is not based in hard science. Yet. And, each of us is different. I guess it's this difference that attracts us to triathlon.

So, as I see you now, I envision someone who is happy in the sport, one who gets great joy out of the competition and the work it takes to get to the start line, but wants to make a leap, perhaps a pretty big leap, in improvement. Sounds good. But, some folks in this group will get to some level in training duration, intensity, or both, and the knee starts to act up. And instead of following the dream, they have a seemingly endless list of problems and find difficulty just getting back to base line.

I'd suggest that if you are going to ramp up your training that you do so ridiculously slowly to see if you can't sneak up on this potential problem. I'd ask you to talk with your local sports guy, doesn't need to be an Orthopod, get some weight bearing xrays and a good evaluation to see if there's and discernible degeneration in the joint at this point in time. And then it comes back to you to make the decision that's best for you. (You might even get some benefit from coaching, as much to guide you as to hold you back on your ultimate pursuit. Sort of the "Easy Seabiscuit!" methodology.) In the end you'll make the best decision on the information you gain and I wish you a long and productive triathlon career. Good luck.
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This is not new but it looks like a good time to give it some air.

Cyclists are the biggest sandbaggers and secret
trainers around. They'll say anything to soften you
up for the kill. Don't let this happen to you. Study
this handy rider's phrasebook to find out what they
really mean when they say:

"I'm out of shape"
Translation: I ride 400 miles a week and haven't
missed a day since the Ford administration. I replace
my 11-tooth cog more often than you wash your shorts.
My body fat percentage is lower than your mortgage
rate.

"I'm not into competition. I'm just riding to stay in
shape"
Translation: I will attack until you collapse in the
gutter, babbling and whimpering. I will win the line
sprint if I have to force you into oncoming traffic.
I will crest this hill first if I have to grab your
seat post and spray energy drink in your eyes.

"I'm on my beater bike"
Translation: I had this baby custom-made in Tuscany
using Titanium blessed by the Pope. I took it to a
wind tunnel and it disappeared. It weighs less than a
fart and costs more than a divorce.

"It's not that hilly"
Translation: This climb lasts longer than a
presidential campaign. Be careful on the steep
sections or you'll fall over -- backward. You have a
39x23 low gear? Here's the name of my knee surgeon.

"You're doing great, honey"
Translation: Yo, lard ass, I'd like to get home
before midnight. This is what you get for spending
the winter decorating and eating chocolate. I shoulda
married that cute Cat 1 racer when I had the chance.

"This is a no-drop ride"
Translation: I'll need an article of your clothing
for the search-and-rescue dogs.

"It's not that far"
Translation: Bring your passport

3 Bikers, 3 Crashes, 3 Fractures

2011-06-23T09:10:00.000-04:00

"I got the rockin' pneumonia, I need a shot of rhythm and blues"

Chuck Berry

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Quick note - Caffeine - (From previous blog) I was asked by several about "shakiness" having dosed up on pre-race caffeine, and yes, you are correct. In fact, I was jittery enough that pinning on my race number was a bit of a chore.
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Bike riding is serious business and although we do it for fun, exercise and athletic improvement, all too often we see in this blog and other places that there's much that can happen astride a two wheeler.

In the last year or so, I've had 3 friends crash and I'd briefly like to share both the details of the incident so you don't let yourself get into the same predicament, and the results of their injuries. We'll call these friends Moe, Larry and Curly although collectively they are far from stooges.

Over the Memorial Day holiday, we ran a thread on a tri forum dedicated to those who'd lost their lives while biking in training or racing and the length of the list is astonishing.

"Moe ' is a plaintiffs attorney who's qualified for Kona in the recent past. He was riding his road bike down a fairly steep hill on a local dirt road which he knew well from having ridden both his mountain bike and road bike there in the past. While braking, his ram's horn handle bars became loose, rotated forward, and he lost his ability to brake. He very quickly picked speed, crashed, and suffered a hip fracture like you might expect to see at the nursing home.

At surgery, the fracture was reduced, pinned, and he is now healed. He had blood clots in his leg post op and had to have blood thinning medicine for 6 months. Recently he finished the bike leg of an Ironman 70.3 race in 2:27, second by a minute in his age group. Obviously he's a talented biker.

"Larry" was riding on a quiet hard surface road having just passed over a small rise. Attempting to make a turn, he looked back to clear himself of traffic, but because of the small hill was unable to see a vehicle approaching at a rapid pace...and was struck by it going partially over the hood and windshield before striking the ground. Hard! He fractured two of the bones in his lumbar spine and had a "slight" nerve injury.

He was x-rayed, scanned and braced. And although this is one tough hombre, he needed generous pain medicine, was out of work and most definitely off his bike for a couple months. He's returned to finish our local end of summer century ride under 5 hours over a beautiful but hilly course. He still has occasional back pain.

Lastly, "Curly" a former near National Champion duathlete, and one of the most careful riders I know, while riding in a populated area on a relatively busy street, had a driver suddenly open the door of a parked car. And he rode right into it suffering a fractured pelvis in 4 places!

Following x-rays and scanning, he was quite fortunate that no other internal organ damage occurred and that surgery was not deemed necessary. He was non-weight bearing on crutches until the pain dissipated, was eventually permitted to ride the trainer in his garage, and although now back to riding, has yet to return to his level of peak fitness.

What do these three riders have in common? They were extremely fortunate that even though significantly injured, they're alive and making a good recovery.

Learn from these gents...don't be a stooge.

Images 2, 3, 4 from Google Images

ACL Tears, Part Two

2011-06-19T21:44:00.003-04:00

"The most important truth
is that knowledge is power,
knowledge is safety, and that
knowledge is happiness."

Thomas Jefferson

I guess Tom saw the importance of reading this
blog, too.

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Isn't it interesting that we should be discussing this injury, the same one suffered by Tiger Woods, the world's greatest golfer (but not SUV driver). He very recently pulled out of a golf tournament and, more importantly, bypassed the U.S. Open Championship, a major event that he's won in the past, because of knee pain. Serious stuff.
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Caffeine Update: Not long ago we discussed the use of a "legal PED" or performance enhancing drug, caffeine. It was pointed out that if one is a regular coffee drinker that abstention from the black gold for a period of time was important for the race day dose to be effective.

Well, I've learned over time that a good deal of what's written in magazines is a compilation of what's been written before with the author really having honest knowledge or experience with the subject that he/she is trying to give you advice on. Water running is one of those topics that, in my mind having tried it many, many times with 30 years of intermittent triathlon injuries, is misrepresented in it's ability to get your heart rate anywhere near your training zones. So, I tried what was written about caffeine. And for me, the abstention was more than a week, closer to 3 weeks. No coffee, no caffeinated sodas, tea, etc. But, when you take your 400 or so mg an hour before the race, you know there's a change going on in your body. Whether or not you race faster may be a different matter, just don't always believe what you read even if it's in a reputable magazine or web site that you trust. The author's human too.

In the June 6th blog we discussed the anatomy and function of the anterior cruciate ligament, one of the most important structures in the musculoskeletal system. This blog will cover the findings on physical exam, options for treatment including potential surgery and the post operative course.

Not all knee problems involve ligaments or surgery.

The triathlete being examined for consideration of an ACL tear will usually have a slightly warm, swollen and painful knee. They know there's something wrong with it unlike any injury they may have suffered in the past. At some point in the diagnostic chain someone will want to know if the swelling in the knee is blood or not, always a bad sign. This would be determined by aspirating the joint (putting a needle in.) Various tests to determine the status of the ligament would be performed by the examiner, plain x-rays obtained to rule out fracture, and potentially an MRI to confirm the exam findings.

Note on MRI's: too frequently, be it in the office or on a triathlon forum, the participant/patient's answer to knee pain, regardless of etiology or other information, "Well, let's get an MRI," as if they are free. With a cost of anywhere between $750 and $2000 per scan perhaps judicious use of this valuable resource would be best in situations where other diagnostic tools have failed.

After the exam and studies are complete and the diagnosis of ACLT made one has to decide whether or not to reconstruct it. Note this does not say repair because when this ligament ruptures it is not repairable. The low demand elderly patient might not be chosen as a candidate for surgery or those in which the rupture was a freak accident and the patient won't be stressing the joint in life or sport. That said, I would imagine that most reading this are now and wish to remain athletically active and most likely will undergo some type of reconstructive procedure. This is especially true to prevent later damage to other structures in the joint from giving way episodes in the future. What is done and how it's done varies considerably on patient age, personal preferences and experience of the surgeon.

Generally this surgery is done arthroscopically as an outpatient and the recuperative period is approximately 5 - 6 months. Lastly, it's important to remember that when this ligament tears, other parts of the knee are also injured although perhaps on a sub clinical level. This would mean that even after the most perfect operation and rehab, the knee is neither the way it used to be nor normal. There's an excellent chance that it will function quite well...for a while... but eventually most ACL damaged knees will deteriorate with time.

Images 1, 3 Google Images