Personal Best

But First, Doctor, What Was Your Marathon Time?

HIPPOCRATES THE OLYMPIAN Athletic patients may want to find physically fit physicians.

YOU are an athlete, or, at least, very active. Should you seek doctors who are athletes, too? After all, some obese people pass around lists of “fat friendly” doctors who treat them with respect. Women often want female doctors.

Are athletes also a special group? And, if so, do they fare any differently if they see doctors who are athletes?“Nobody knows,” said Dr. James Fries, a 20-mile-a-week runner and a professor of medicine at Stanford. “There’s no data.”

There are some hints, though, said Dr. Ronald Davis, who is the president of the American Medical Association and a specialist in preventive medicine at the Henry Ford Health System, which includes hospitals, clinics, a managed-care plan and a large physician group practice.

Dr. Davis cited a study by Dr. Erica Frank, who is now at the University of British Columbia. Her study, published a few years ago, involved a survey of about 4,000 female doctors and found that those who were at least moderately active were much more comfortable advising patients about exercise and encouraging them to exercise.

A doctor who is physically active, Dr. Davis said, “is more likely to provide advice on exercise that will be meaningful to patients.”

That stands to reason, Dr. Fries and other physicians said. Doctors who are athletes, he added, are less likely to say “untoward things like that running destroys the knees or that you need an electrocardiogram before you can exercise.”

But it is not always obvious whether a doctor is an athlete. Some tell their athletic patients about their exploits. Some have photos in their offices showing them crossing finish lines. With others, though, unless you ask, you may never know.

Of course, good doctors can be sedentary and terrible doctors can be athletic. What matters most is the doctor’s skill and training and whether you feel comfortable with the doctor. Some active people, in fact, say they had an awful experience when they sought out an athletic doctor.

But in general, doctors who are athletes tend to be more aware that active people want to stay active more than anything else, said Dr. William Kraus, 53, a cardiologist who is a professor of medicine at Duke and runs 35 miles a week and finishes 5-kilometer races in about 20 minutes. He said athletic doctors are less likely to take the easy way out and tell an active person who is injured or ill to stop exercising.

“For many of us, that’s just unacceptable,” Dr. Kraus said.

That was the reaction of Richard Hulnick, 40, a manager for business development at the New York Road Runners, when an orthopedist told him to stop running. He saw the doctor because his knee was bothering him. But the doctor, who, Mr. Hulnick said, “did not look like an athlete,” told him to take up another sport.

“I wanted to get better,” Mr. Hulnick said. “I wanted someone to work with me, but he didn’t tell me what to do.” So Mr. Hulnick walked out of the doctor’s office and resumed running. His knee recovered on its own and he never saw that doctor again, he said. Since then, he has completed six marathons and an Ironman distance triathlon.

Dr. Paul Thompson, a 60-year-old marathon runner (he finished second in his age group in the Chicago Marathon last year) and the director of cardiology at Hartford Hospital in Connecticut, said he often finds himself giving different advice to athletes than he would to more sedentary patients.

For example, he said, a woman with a malfunctioning heart valve came to him for a second opinion. Another cardiologist had told her there was no need to replace the valve because the woman had no symptoms. But she had been a competitive triathlete. So when she told Dr. Thompson that she had recently run a five-mile race in 50 minutes, he was suspicious. He asked her if that was her usual pace, and she told him that her time was actually much slower than in the past.

“To me, it was quite clear she was limited in her exercise tolerance,” Dr. Thompson said. He recommended she have the valve replaced, and she did.

Dr. William Roberts, a runner, skier and sailboat racer who is a professor of family medicine at the University of Minnesota, said active people sought him out to such an extent that his practice gradually turned into one made up mostly of athletes.

“They know I like physical activity and I am willing to try to find ways to keep them active,” said Dr. Roberts, a former president of the American College of Sports Medicine. He recently saw a patient with atrial fibrillation, a heart disorder. The man said other doctors had told him to stop exercising, so he had come to Dr. Roberts hoping to hear a different message.

He did. Dr. Roberts said he told the man that he could exercise as long as he kept his heart rate from going too high, and as long as he had no chest pain or shortness of breath.

Some athletes, like Jon Luff, a 40-year-old aerospace engineer who ran the New York City marathon in 2:39:59 said that if experience is any guide, stay away from doctors who know nothing about training. Mr. Luff’s wife is a doctor, as are three close friends, so he said he shouldn’t speak too freely. But then, just thinking about doctor problems, the floodgates opened.

“I have a story concerning heart rates,” Mr. Luff said. “I have one concerning tendinitis. I had a doctor tell me once that I had mono and had to stop everything.” Mr. Luff was 18 at the time and withdrew from two national competitions. It turned out he had only a cold.

Mr. Luff also has a good friend, Bill Burke, who was initially turned down by the Air Force because he has a resting heart rate of 33. Mr. Burke, who was the national champion in 1,500 meters in 1993, said he had to go to a cardiologist for a medical waiver, which allowed the Air Force to accept him. The cardiologist, Mr. Burke said, told him, “You’re either about to check out, or you’re going to be around for a very long time.”

Then there is the story of a Harvard professor, a surgeon. “He once told me that nobody should run marathons because it destroys knee cartilage,” said Mr. Luff, who knows, however, that most research, including a major study by Dr. Fries, has found that runners actually have a lower risk of knee arthritis.

Yet not every mistaken doctor is a nonathlete. Those who are athletes can be wrong, too.

That is what Patricia Sener, 43, an open-water swimmer who lives in Brooklyn, discovered when she had a problem and went to a doctor who specialized in treating athletes. The doctor pointed to a gray spot in an M.R.I. of her knee and told her she might need a major operation to replace her anterior cruciate ligament. But he said he would not know for sure until she was on the operating table.

“I’m training for the English Channel,” Ms. Sener said. “I’m on a time line. I can’t afford six months off.”

She went to a different doctor, a swimmer, for a second opinion.

“He pointed to the exact same spot on the M.R.I. and said: ‘See this. It’s normal.’” All she needed, she said, was physical therapy to strengthen the connecting muscle and ligaments around her knee and stabilize it. She recovered.

Athletes, though, are not the easiest patients, doctors said.

“They drive you nuts,” Dr. Thompson said. “They are very demanding. They are innately a select group, and a lot of athletes have a superior attitude. They are a little bit defensive.”

They tend, in fact, to be like one of my running partners, who told me that when it comes to a diagnosis, she regards doctors mainly as a source for a second opinion. The first opinion is her own, she said.

Perhaps the best indication of whether athletes should seek fit doctors is to ask doctors who are athletes whether they choose athletic doctors for themselves.

Dr. Roberts said there was no question: he chose a doctor who is an athlete, and so did his wife, a skier. His doctor, David Thorson, is a skier who was his partner when he was in private practice.

“I recruited him in the early 1990s after we raced against each other in sailboats,” Dr. Roberts said. He has been Dr. Thorson’s patient ever since.

A patient passed this on to me recently. New York Times January 3, 2008

A copy of the original article can be found at: http://www.nytimes.com/2008/01/03/health/nutrition/03Best.html?ex=1357102800&en=ab0c7b339e565219&ei=5124&partner=permalink&exprod=permalink

We have conventionally treated soft tissue injuries with anti-inflammatory medication (ibuprofen and naproxen).  However, we now know that inflammation is necessary to promote healing; to make the tissue stronger and faster; and stronger faster.

A method designed to promote inflammation and healing, called Prolothrapy, is gaining main stream recognition (even by the Richmond Times Dispatch , August 16, 2007).  The treatment involves a series of injections of dextrose and saline (sugar water, ie- all natural and safe).  The shot is an “irritant;” so it causes a local increase in the bodies own natural inflammation and healing factors.  This directly stimulates the growth of healthy, strong tissues. As the tendons and ligaments grow stronger and more capable of doing their tasks, the pain is alleviated. Prolotherapy starts the growth of ligaments and tendons, but an individual’s own immune system grows the tissue.

Prolotherapy is extremely safe. It is less risky than taking ibuprofen to temporarily alleviate chronic pain. Your Sports Medicine provider will review possible risks and benefits with you.

Most athletes require four or five sessions. For someone with an injury for just a few months (or less) and is in excellent shape, the number of sessions may be even less

Most Medical insurance companies cover this simple, safe procedure.

If so you may have “Shoulder impingement Syndrome,” also known as “Subacromial Bursitis,” and “Tendonitis.” This common condition affects at least half of all overhead athletes at some point in their career.

To understand Impingement Syndrome, it helps to know the bones and a few muscles of the shoulder. The shoulder consists of 3 bones: the collar bone (clavicle); the arm bone (humerus); and the shoulder blade (scapula) (figure 1). The ball and socket of the shoulder moves in many directions; in fact, the shoulder is the most mobile joint of the body. The socket is shallow and the ball is relatively large. It’s analogous to taking a golf tee and balancing a basketball on top of it- an unstable situation.

This very mobile joint is supposed to be made stable by 4 small muscles collectively called the “rotator cuff.” Most people do not regularly strengthen their rotator cuff muscles and therefore have a “lose” or lax shoulder joint. Then we take this lax joint and stress it with throwing, hitting, and serving after a winter of doing no such things.

One of the four rotator cuff muscles, the spraspinatous, passes thru a tunnel in the middle of the shoulder (figure 2). This tunnel is narrowed every time you lift your arm up overhead (figure1).

The thin supraspinatus muscle gets crushed or impinged in the tunnel. When it gets crushed, it wants to get red, angry, and inflamed. The muscle tries to swell. However, because it is living in a tight tunnel, there is nowhere for the swelling to go. So it hurts. When it hurts, it tries to swell even more. Again, nowhere for swelling to go. You get the picture: impingement causes swelling, which causes pain, which in turn causes more swelling. This impingement is most severe when the rotator cuff is weak and the shoulder joint is lax.

Shoulder impingement typically causes pain down the outer side of the shoulder, half way to the elbow. The pain is worse with reaching overhead, and while trying to sleep. Your Sports Medicine doctor can put you through a series of maneuvers that can confirm the diagnosis of shoulder impingement. Once this diagnosis is made, there are a number of things that may be done to get you better. When recommending appropriate treatments, your Sports Med provider will take into account where you are in your athletic season. Here are some things that may be tried.
• Initially, decreasing overhead activities may help. Try to cross train by doing other drills and playing other positions.
• Ice three times a day for 20 minutes and anti-inflammatory medications may help decrease the swelling in the tight tunnel where the supraspinatus lives.
• A cortisone injection right into the tunnel around the supraspinatus may be tried.
• Strengthening and stretching the entire rotator cuff is important while healing occurs. Your rehab program will be costumed to your specific needs and to correct your specific weaknesses.
• Physical therapy modalities like ultrasound may be prescribed.
• Surgery may be discussed as a very last resort after getting no improvement with a good treatment program for over a year.