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

Take a look at one Lois Cramer and her recent publication showing all she has achieved.  We passed the article around the office and everyone at CSM is so proud of you.

A google search of PFS yielded 150 thousand hits. In fact PFS is so common that it affects 10% of male runners and a woping 50% of female runners at some point in their lives.

PFS pain is felt behind the kneecap or patella. It may feel like a sharp pain or like a dull ache. You may feel popping in your knee when you bend your leg.

The problem is worse with hill work and may be worse with a sudden increase in mileage. Loading a bent knee as in going up or down stairs also hurts. Riding in your big chain ring may make PFS worse. It is particularly painful with prolonged sitting with bent knees, or when getting up after sitting for a long time.

What causes PFS?
Like we said, PFS is poorly understood. But here is the best we have to date:
Normally the kneecap (patella) lives in front of the thigh bone (femur) in a groove that is lined with cartilage, a sensitive material (Figure I).

As the knee bends and straightens, the patella glides up and down in the groove. The muscles that hold the patella in the groove come from the thigh. If those muscles are too weak to hold the patella right in the middle of the groove, the kneecap knocks on the sidewalls of groove. The patella tracks toward the outer (lateral) edge of the femur. This off-kilter path damages the cartilage between the patella and the femur and causes pain.

PFS is more likely to happen in people who have feet that pronate; a wide pelvis; or weak quadriceps (thigh muscles). The problem also occurs in bicyclists with excessive side-to-side knee motion on the downstroke.

What can be done about PFS?
The good news is that surgery is not the cure to this condition. But the bad news is that fixing PFS usually requires lots of rehab and hard work.

Start with the standard cure-alls: cross training and ice. That will be enough for some cases of PFS. The remainder will need a specific quadriceps strengthening, hamstring stretching and general conditioning program to fix any muscle imbalances. The program will be designed to “straighten” the improper tracking pattern of the patella on the femur. A Sports Medicine provider can devise such a program for you.

Motion control shoes, a shoe insert, or even orthotics may be necessary to help the pronator with PFS. A knee brace with a cut out hole for the patella may assist the misalignment problem. Similarly, taping the kneecap into a specific position during workouts may help reduce PFS pain.

In more sever cases, injecting the knee with a viscous lubricant helps reduce the pain from cartilage damage behind the patella. A good Sports Medicine physician can determine whether you are a candidate for this type of treatment.

Here are some tips to help ensure athletes stay at their best and prevent heat-related injuries during two-a-days.
Encourage Athletes to Begin Conditioning Before Two-A-Days
Encourage athletes to begin conditioning in the heat two weeks before official practice begins. This allows athletes’ bodies to cool more efficiently by increasing sweat production sooner than when they are not acclimated to the heat.
ACCLIMATE:
1. Acclimatization will reduce the negative impact of heat on athletic performance.
2. Acclimatization is most effectively achieved by exercise in the heat; heat without exercise and exercise without heat are less effective.
3. Acclimatization can be carried out by exercising in a hot room or by training in a hot climate.
4. The major physiological adjustments to heat acclimatization take about 7-14 days.
5. Training volume and intensity should be reduced on first exposure to the heat and then gradually increased. Some high-intensity training should be maintained throughout the acclimatization period.
6. Reducing the intensity and duration of the warm-up may be necessary to keep core temperature from rising too high before training and competing in the heat.
7. Monitoring responses of individual athletes is essential — individuals respond differently to physical activity in the heat.
8. Records of body mass, urine output and color, and subjective symptoms should be kept by athletes and reviewed periodically by coaches and trainers.
9. Acclimatization increases the athlete’s need for fluid to match the increase in sweat rate.
10. Dehydration impairs performance and negates the beneficial effects of acclimatization.

Avoid Workouts During Unusually Hot Temperatures
Practice sessions during unusually hot and humid conditions should be limited to very moderate workouts, postponed until cooler times of the day or brought inside to avoid the heat.
Make Fluids Part of the Playbook
Before, during and after competition, be sure to consume adequate amounts of fluid. Athletes can make sure they are properly hydrated by checking their urine color: lighter urine color indicates athletes are better hydrated. The longer the workout session, the more frequently fluids need to be replaced. Research shows
that a sports drink containing a 6% carbohydrate solution, like Gatorade, can be absorbed as rapidly as water. But unlike water, a sports drink can provide energy, delay fatigue and improve performance.
Signs of Dehydration and Heat Illness
Dehydration can seriously compromise athletic performance and increase the risk of exertional heat injury. That’s why it’s important to recognize the warning signs.
• Thirst
• Irritability
• Headache
• Weakness
• Dizziness • Cramps
• Nausea
• Decreased performance

Use the Shade
Before practice, warm up in the shade and be sure to rest in the shade during breaks. Even during rest, exposure to heat can raise the body temperature, increase fluid loss and decrease the blood available to the muscles during workouts.
Recommend Wearing Loose Fitting Clothing
Cotton blend, loose fitting clothing can help promote heat loss. The rule: the less clothing, the better.
Be Prepared for an Emergency
Always have a cell phone on hand and be familiar with emergency numbers. Also keep ice and ice towels on hand in case of heat-related emergencies.
Fluid Guidelines for Two-A-Days
Proper hydration is the best safeguard against heat illness. Remember to have athletes drink before, during and after training and competition.

Before Exercise
• 2 to 3 hours before exercise drink at least 17 to 20 oz of water or a sports drink.
• 10 to 20 minutes before exercise drink another 7 to 10 oz of water or a sports drink.

What to Drink During Exercise
Drink early—Even minimal dehydration compromises performance. In general, every
10 to 20 minutes drink at least 7 to 10 oz of water or a sports drink. To maintain hydration, remember to drink beyond thirst. Optimally, drink fluids based on amount of sweat and urine loss.
• Athletes benefit in many situations from drinking a sports drink containing carbohydrate.
• If exercise lasts more than 45 to 50 minutes or is intense, a sports drink should be provided during the session.
• The carbohydrate concentration in the ideal fluid replacement solution should be in the range of 6% to 8% (14 to 18 g/8 oz).
• During events when a high rate of fluid intake is necessary to sustain hydration, sports drinks with less than 7% carbohydrate should be used to optimize delivery.
• Cool beverages at temperatures of 50° to 59° F are recommended.

What Not to Drink During Exercise
• Fruit juices, carbohydrate gels, sodas and those sports drinks that have carbohydrate levels greater than
8% are not recommended as the sole beverage.
• Beverages containing caffeine, alcohol and carbonation are discouraged during exercise because they can dehydrate the body by stimulating excess urine production, or decrease voluntary fluid intake.
After Exercise
Immediately after training or competition is the key time to replace fluids. Weigh athletes before and after exercise. Research indicates that for every pound of weight lost, athletes should drink at least 20 oz of fluid to optimize rehydration. Sports beverages are an excellent choice.

Managing Two-A-Days
Stay Cool
• Get in shape and acclimate
• Know the warning signs of dehydration and heat illness
• Drink on schedule
• Monitor body weight
• Watch urine color and caffeine intake
• Key in on meals as an opportunity to increase fluid intake
• Stay cool when you can
From: Eichner, E.R. (1998). Treatment of Suspected Heat Illness. Int. J. Sports Med. 19:S150-153.

Stay Healthy
• Minimize the stresses of life
• Avoid salt tablets as these don’t meet an athlete’s fluid needs.
• Avoid carbonated beverages, which may cause bloating and reduce the amount of fluid consumed
• Eat a well-balanced diet
• Avoid overtraining
• Sleep well
• Avoid rapid weight loss
• Avoid people with colds
• Keep hands away from nose and mouth
• Get a flu shot
• Stay hydrated and ingest carbohydrates during exercise

Stay Hydrated
• Drink throughout the day
• Drink at least 17 to 20 oz of fluid 2 to 3 hours before a practice or game
• Drink an additional 7 to 10 oz of fluid 10 to 20 minutes before competition
• Drink 28 to 40 oz of fluid per hour of play (at least 7 to 10 oz every 10 to 15 minutes) to replace sweat loss during exercise
• Drink at least 20 oz per pound of weight loss within two hours of finishing training or competition
• Optimal to have fluid intake match sweat and urine loss.
From: Casa, D. et al. Journal of Athletic Training 35(2): 212-224, 2000.

That ice pick stab into the bottom of your heal when you step out of bed in the morning is probably caused by plantar fasciitis (fashee-EYE-tiss).

The plantar fascia is a band of tissue that goes from the bottom of the heel (calcaneus) to the ball of the foot (metatarsal heads), as seen here.

Its primary job is to support the arch on the bottom to the inner foot.

A normal plantar fascia can get over- stretched by factors acting to flatten this arch. When the arch is over stretched, the plantar fascia pulls on the heal bone. Over time, this causes pain and degeneration of the fascia where it originates on the heel. The condition is called plantar fasciitis

Many factors can inappropriately stretch the plantar fascia, but being overweight is the most modifiable factor. Many people with plantar fasciitis are overweight. Doing sports that involve repetitive pounding, like distance running, is also a risk factor. In fact, plantar fasciitis affects al least 10 % of runners at some point in their life. Overpronation (foot rolling in) flattens out the normal foot arch, thereby stretching the plantar fascia. Pronation is a potentially correctable risk factor. Shoes with broken down arch support can also contribute to plantar fasciitis.

Before treating yourself for this condition, you deserve a trip to your Sports Medicine provider to make sure that you do not have a less common condition like a stress fracture, a compressed nerve, or an inflamed growth plate.

There are many ways to treat plantar fasciitis because none of the treatments are perfect. Since this is not an inflammatory problem, anti-inflammatories (like ibuprofen and naprosen) do not help much.

Plantar fasciitis is actually a mechanical problem. So treatment should focus on changing mechanical factors. Lengthening the fascia while avoiding overstretching is a good idea. Even more important is strengthening the arch so that it does not pull on the heal bone. Specific treatment recommendations are:
• If you are overweight, work on some cross training for a while to shed the pounds. Water running, swimming, and bicycling will not stress the plantar fascia. Even a 10-pound weight loss makes a big difference. Since running transmits 5X your body weight through your foot, a 10-pound loss translates into 50 pounds less at the sole of the foot.
• Back down on running mileage by about 50 percent. Consider it a blessing to be forced to work on cross training with biking, swimming, or other sports.
• Strengthen the arch by making a “fist” with you foot; relax; then do it again. Do enough reps of this exercise to exhaust the muscles on the bottom of your foot.
• Stretch after workouts as well several times during the day. It is important to stretch out both the plantar fascia and the Achilles tendon, since both structures attach to the heal bone. Two good stretches are shown here. Never stretch cold tissue (this causes the tissue to tear). Hold each stretch for at least 30 seconds. Keep the stretch comfortable- it should not cause excessive pain.
Lean forward against a wall with the affected side knee straight and heel on the ground. Your other knee is bent. Your heel cord and foot arch stretch as you lean forward. Repeat the same stretch with the back knee slightly bent, keeping the heal on the ground.
My Aching Heal

That ice pick stab into the bottom of your heal when you step out of bed in the morning is probably caused by plantar fasciitis (fashee-EYE-tiss).

The plantar fascia is a band of tissue that goes from the bottom of the heel (calcaneus) to the ball of the foot (metatarsal heads), as seen here.

Its primary job is to support the arch on the bottom to the inner foot.

A normal plantar fascia can get over- stretched by factors acting to flatten this arch. When the arch is over stretched, the plantar fascia pulls on the heal bone. Over time, this causes pain and degeneration of the fascia where it originates on the heel. The condition is called plantar fasciitis

Many factors can inappropriately stretch the plantar fascia, but being overweight is the most modifiable factor. Many people with plantar fasciitis are overweight. Doing sports that involve repetitive pounding, like distance running, is also a risk factor. In fact, plantar fasciitis affects al least 10 % of runners at some point in their life. Overpronation (foot rolling in) flattens out the normal foot arch, thereby stretching the plantar fascia. Pronation is a potentially correctable risk factor. Shoes with broken down arch support can also contribute to plantar fasciitis.

Before treating yourself for this condition, you deserve a trip to your Sports Medicine provider to make sure that you do not have a less common condition like a stress fracture, a compressed nerve, or an inflamed growth plate.

There are many ways to treat plantar fasciitis because none of the treatments are perfect. Since this is not an inflammatory problem, anti-inflammatories (like ibuprofen and naprosen) do not help much.

Plantar fasciitis is actually a mechanical problem. So treatment should focus on changing mechanical factors. Lengthening the fascia while avoiding overstretching is a good idea. Even more important is strengthening the arch so that it does not pull on the heal bone. Specific treatment recommendations are:
• If you are overweight, work on some cross training for a while to shed the pounds. Water running, swimming, and bicycling will not stress the plantar fascia. Even a 10-pound weight loss makes a big difference. Since running transmits 5X your body weight through your foot, a 10-pound loss translates into 50 pounds less at the sole of the foot.
• Back down on running mileage by about 50 percent. Consider it a blessing to be forced to work on cross training with biking, swimming, or other sports.
• Strengthen the arch by making a “fist” with you foot; relax; then do it again. Do enough reps of this exercise to exhaust the muscles on the bottom of your foot.
• Stretch after workouts as well several times during the day. It is important to stretch out both the plantar fascia and the Achilles tendon, since both structures attach to the heal bone. Two good stretches are shown here. Never stretch cold tissue (this causes the tissue to tear). Hold each stretch for at least 30 seconds. Keep the stretch comfortable- it should not cause excessive pain.

Lean forward against a wall with the affected side knee straight and heel on the ground. Your other knee is bent. Your heel cord and foot arch stretch as you lean forward. Repeat the same stretch with the back knee slightly bent, keeping the heal on the ground.

Put the ball of the foot on a wall, leaving the heal on the floor. Gradually lean your body toward the wall. Do this with the knee straight, and then repeat with the knee slightly bent.
• Ice after stretching and strengthening for 15-20 min. Massage with a frozen paper cup is very beneficial. Heat-strength-stretch-ice should go in that order.
• Proper footwear is necessary. Shoe inserts may help correct misalignments. An arch support insole can help by providing a continuous mild stretch. There are many such insoles available. Check with your Sports Med provider to determine what your footwear needs are.
• Similarly, your Sports Med provider may use athletic tape to hold the arch up, thereby providing a constant gentle stretch.
• There are many types of night splints available. These splints lengthen out the plantar fascia while you sleep. These may help a great deal if your symptoms are worse when you first step out of bed in the morning. The best splints stretch the arch of the foot; not just the Achilles tendon.
• Cortisone injection may be attempted. This is generally a temporary fix, and may weaken the fascia in the long term.
• Shock wave therapy is a fairly new treatment (although it has been used in other countries for many years). Applying strong shock waves to the plantar fascia helps stimulate healing of the degenerated tissue.
• Surgery should be kept as a last resort and is falling out of use as shock wave therapy becomes more available.

Put the ball of the foot on a wall, leaving the heal on the floor. Gradually lean your body toward the wall. Do this with the knee straight, and then repeat with the knee slightly bent.
• Ice after stretching and strengthening for 15-20 min. Massage with a frozen paper cup is very beneficial. Heat-strength-stretch-ice should go in that order.
• Proper footwear is necessary. Shoe inserts may help correct misalignments. An arch support insole can help by providing a continuous mild stretch. There are many such insoles available. Check with your Sports Med provider to determine what your footwear needs are.
• Similarly, your Sports Med provider may use athletic tape to hold the arch up, thereby providing a constant gentle stretch.
• There are many types of night splints available. These splints lengthen out the plantar fascia while you sleep. These may help a great deal if your symptoms are worse when you first step out of bed in the morning. The best splints stretch the arch of the foot; not just the Achilles tendon.
• Cortisone injection may be attempted. This is generally a temporary fix, and may weaken the fascia in the long term.
• Shock wave therapy is a fairly new treatment (although it has been used in other countries for many years). Applying strong shock waves to the plantar fascia helps stimulate healing of the degenerated tissue.
• Surgery should be kept as a last resort and is falling out of use as shock wave therapy becomes more available.

ANATOMY

The hamstring muscle group consists of three muscles (biceps femoris, semitendinosus, semimembranosus) that originate on the ischial tuberosity (sit bone) and inset on the 2 bones of the lower leg. Hamstring contraction causes the knee to bend and the thigh to swing backward- 2 important motions in running and bicycling.

Muscle strain is typically divided into 3 degrees of severity:
1) A grade I strain is mild. Only a few muscle fibers are disrupted. There is a bit of pain and swelling, but the muscle remains strong.
2) Grade II strains involve larger partial muscle tears. The tear results in some strength loss.
3) With a grade III strain there is a complete tear of one or more of the 3 hamstring muscles. This severe injury and is quite disabling.

PREVENTION
Avoiding “TOO MUCH TOO SOON” is key to the prevention of hamstring strain. Typical culprits of this injury are 1) increasing mileage by more than 10% per week (remember to obey the 10% rule), 2) too much speed work or down hill running, and 3) tight muscles. When we run sprints or down hill, our hamstrings work overtime, trying to slow us down while in a stretched position. This simultaneous contraction while stretching is called an “eccentric contraction.” Eccentric contraction exercises should always increase GRADUALLY; if not, injury will ensue.

In the medical literature, the jury is still out about weather or not stretching can actually prevent hamstring strain. Some studies conclude that stretching helps while most say it makes no difference. Most of these studies do not have their subjects perform adequate stretching. In other words, for hamstring stretching to possibly be effective, it must be done correctly, held for at least 20 seconds and repeated frequently though out the day.

TREATMENT
What if it’s too late… you’re already suffering the deep ache on the back of your thigh… wishing this article had been out a month ago. Hamstring strain frequently recurs and becomes chronic. So proper treatment early on is essential. Take a visit to your health care provider in order to get a correct diagnosis and to coordinate treatment.

Treatment of muscle strain is divided into several stages, which coincide with stages of muscle healing. Initial rehabilitation is designed to decrease pain and inflammation. Next, a couple of weeks are dedicated to stimulate collagen healing. Maintaining fitness during this stage is easy for the mutli-sport athlete who can replace running with other sports. Of coarse the rate of progression through rehabilitation depends on the severity of the strain. The rehab process continues for several months, keeping muscles strong to avoid reinjury.

Stage I, Week 1:     decrease pain and swelling     P.R.I.C.E.: Protection (walk with crutches if limping to avoid other injuries);     Relative Rest (if it hurts, don’t do it); Ice (a bag of frozen peas and an ace wrap works great);     Compression (the ace wrap); Elevation (higher than your heart).
Stage II, Weeks 2 to > 3: control pain, align and strengthen new collagen, maintain conditioning with submaximal strength exercises; bicycling without clips or straps (to avoid vigorous “pulling up” on pedals); swimming with pull buoy.
Stage III: Weeks 4- 6: maintain strength and flexibility, increase eccentric strength Stretching; strengthening; jump rope; light jog; run

Return to more normal workouts may ensue when:
1) Pain is gone.
2) The strength on the injured side is 90% that of the normal side.
3) Flexibility and coordination are normal
With return to full activity, any hamstring tightness should be a warning sign that perhaps workouts were begun too soon. Talk to your health care provider again to re- evaluate and perhaps rewind the rehabilitation.

Happy Trails!

-Dr. Stadler

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.

Greetings Knee’ding,

You have lots of company and do not need surgery. Iliotibial Band Syndrome (ITBS) is the most common cause of knee pain in runners. Surgery is not necessary.

The Iliotibial Band (ITB) is a muscle and tendon that goes from your outer hip (or ilium), down your entire thigh, into a spot on the shinbone (tibia), just below your knee. It is very important in stabilizing the pelvis when you run. A strong ITB prevents side-to-side hip motion during the stance phase of running.

This important tissue passes back and forth over the thigh bone with every step you take. As it does this, it rubs on a bump or condyle on the bottom of the thigh bone. At the spot where the ITB rubs over the condlye, friction builds up, resulting in inflammation and swelling.

The pain of ITBS may come on worse after a rapid milage increase; a tough hill workout; overstriding; a long run on a cambered road; inadequate stretching.

If you have bowlegs, ITB tightness, or unequal leg lengths, you may be more likely to get ITBS. A good Sports Medicine physician can make recommendations for treating these predisposing conditions.

We already said that surgery is not the answer to this condition. There are a few things you can do decrease the pain of ITBS and prevent it from returning:
• Decrease your mileage by 25-50% until your nearly all better. Cross train to maintain fitness. Water running and elliptical training are great.
• Put hill work on hold for a while.
• Alter your pace. If you usually run 8 minute miles, try running a few 9s, then a few 7:30s. This changes the angle of the knee during footstrike and may decrease the irritation of the ITB over the thigh bone.
• Strengthen the ITB so it can easily do its job of stabilizing the pelvis. Stretch the ITB during and after your sworkouts. Stretching should initially be done several times a day. A good Sports Medicine provider can teach you appropriate exercises.
• Ice the affected area after your workouts.
• Alternate running direction on cambered surfaces and avoid very pitched roads all together.
• A lateral heak wedge may decrease the predominance of the thigh condyle, thereby decreasing ITB friction and irretation.
• A cho-pat band or strap worn just above the sore area helps by decreasing the rub of the ITB over the bone and by changing the mechanical end of the tendon.
• Anti-inflamatory medications may help.
• Physical Therapy modalities like phonophoresis may help.
• Corticosteroid injections work very well for ITBS, but should be reserved for those with more than 6 months of problems or those that need to get better quickly for an important race.

Sports massage should play an important part in the life of any triathlete whether they are injured or not. Massage has a number of physical benefits.
Massage can :
Cure and restore mobility to injured muscle tissue.
Boost performance.
Extend the overall life of your sporting career.

Effects of massage are:
Pumping - The stroking movements in massage suck fluid through blood and lymph vessels. By increasing the pressure in front of the stroke, a vacuum is created behind. This is important in tight or damaged muscles as an overused muscle will squeeze blood out like a sponge, depriving the tissues of oxygen and healing factors.
Increased tissue permeability - Deep massage causes the pores in tissue membranes to open, enabling fluids and nutrients to pass through. This helps remove waste products like lactic acid and encourages muscles to take up oxygen and nutrients which help them recover quickly.
Stretching - Massage can stretch tissues that could not be stretched in the usual methods. Bundles of muscle fibers are stretched lengthwise as well as sideways. Massage can also stretch the sheath or fascia that surrounds the muscle, so releasing any tension or pressure build up.
Break down scar tissue - Scar tissue is the result of previous injuries or trauma and can affect muscle, tendons and ligaments. This can lead to inflexible tissues that are prone to injury and pain.
Pain reduction - Waste products in muscles causes pain. Massage helps reduce this in many ways including releasing the bodies endorphins. In fact, massage patients are 20 times less likely to be sore after a tough workout.
Anxiety reduction - through the effects mentioned above relaxation is induced and so reduces anxiety levels. In many studies massage can reduce anxiety more than medications can.

Before we jump into how to maintain fitness and train through an upper respiratory infection (URI or “cold”) lets take a look at a few other conditions that can masquerade as a “cold.”

“Mono”
Back in high school you probably heard of the “kissing disease,” Infectious Mononucleosis. While the Epstein Barr virus that causes “mono” is in fact spread by kissing, it can also be transmitted by any method of sharing saliva. So, don’t share water bottles.

Like the common cold, “mono” causes a sore throat and fatigue. However, unlike a cold, “mono” brings fever, swollen neck glands, and possibly spleen swelling. Since a swollen spleen may rupture (and it does in about 2 in 1,000 “mono” patients), workouts should be curtailed for about 3 weeks.

There is no cure for “mono.” Antibiotics will not help and may even make things worse. A Sports Medicine provider will probably recommend symptomatic treatments to help with the fever and sore throat. Adequate rest is very important.

“The Flu”
By now you should have had your influenza vaccination. If not, stop what you’re doing, and go to your doctor’s office for a shot. Influenza, “the flu,” is a common viral infection. The vaccination (ie.- “flu shot”) is 90% effective at preventing infection. Since the vaccine is made of killed virus, the chance of having an adverse reaction to the injection is even less than the possibility of dying from the flu without the shot. In summer, 2007, the CDC reiterated a previous recommendation that “all persons, including school-aged children, who want to reduce the risk of becoming ill with influenza or of transmitting influenza to others, should be vaccinated.”

“The flu” may act like a bad cold, causing fatigue and congestion. But the hallmarks of “the flu” are fever, severe body aches, and dry cough. You feel like you did the day after your personal best running race….without the euphoria. It is contagious- flu symptoms show up about 2 days after an exposure. The infected person is contagious to someone else from 1 day before becoming sick and for the first 6 days of illness. With enough rest, symptoms last about 7 days. Getting to a healthcare provider within 2 days of starting symptoms is critical if one is interested in getting a prescription for an anti-viral medication. When taken with in the first 2 days, these medications help speed recovery.

“A Cold”
This brings us to the common cold, upper respiratory infection, URI, or simply the crud. We all know what a URI feels like. But, what should it not feel like? Fever, difficulty breathing, and vomiting, are not part of a cold. In general, “cold” symptoms are from the neck up: headache, sore throat, and runny nose. The rule of thumb is this: If your symptoms are from the neck up, it’s OK to train if you feel like it. Some over the counter (OTC) medications might help.

OTC decongestants help “dry up” a runny nose. Decongestants also dry up your mouth, making you feel thirsty. Stay away from them before a sanctioned race. All decongestants are banned by the NCAA, USOC, and most sanctioning bodies.

An expectorant, like guaifenecin, is a medicine that “thins” secretions, making it easier to get the bad stuff out. Expectorants are legal in competition. If you try an OTC or prescription form, be sure to get plenty of fluids; don’t get to the point where you feel thirsty.

While your waiting the 5-10 days for the cold to go away, do a few more weight training workouts instead of cardio workouts. That way you can keep your strength up, and eliminate the congestion/ dehydration problem. Plenty of vitamin C (some chewable brands taste good) may help speed recovery and prevent relapse. Try to get at least 1500 mg/ day. Other alternative remedies like zinc and echinacea are also available. They won’t hurt, but well designed studies have not shown them to be very effective.

As for prevention, frequent hand washing is the way to go. The little rhinovirus doesn’t stand a chance against suds and water.

Keep training. Take a few days of rest when needed. Enjoy!