Monday, February 23, 2009

Osteoporosis? Who Me?

I was asked to comment on a piece recently published in the L A Times which noted that cycling, and swimming to some degree, are sports which keep you in shape but are low impact, put little mechanical stress on the skeleton, possible contributing to decreased bone mass. Osteoporosis.

So what is osteoporosis? Essentially it means porous bone, a condition that diminishes bone mass and density. Your bones are not static. They are constantly remodelling related to the stress they undergo. Although we're used to seeing the sequelae of osteoporosis in the elderly manifesting itself as hip, wrist and spine fractures...why grandma keeps getting shorter...but, in truth, as we age bone formation often doesn't keep pace with bone loss. In women, this bone loss accelerates after menopause. It's been noted that in the decade following menopause that women can lose one fifth of their bone density! Definition-wise, osteopenia is diminished bone density, osteoporosis the actual disease state. In osteoporosis, fragility fractures fractures can occur from the simplest of causes, a minor fall, even just sneezing. In fact, I've had patients over the years with broken hips certain that the hip "just broke" before they fell. I believe them!

The potential for osteoporosis affects 55% of Americans over the age of 50, 10-12,000,000 already being affected. 80 plus percent are women, although it's more prevalent in Caucasian females than black and Hispanics. Of concern is the fact that estimates put the number of hip fractures alone at 297,000 in 2005. And, and average of 24% of hip fracture patients over the age of fifty die in the year following their fracture. Those in the risk group might include:
1) Being female
2) Older
3) Diminshed size (and weight)
4) Positive family history
5) History of previous fractures
6) Diet low in calcium and/or vitamin D
7) Inactive lifestyle
8) Smoking

If your doctor feels it appropriate, tests can be obtained which measure bone mineral density. Until then, what do you do? Get regular
weight bearing exercise, avoid smoking and excess alcohol, consume the recommended allowances of calcium and vitamin D (We know that vitamin D comes from the sun and I've taken a vitamin D supplement for years, particularly in the winter.) Be aware that this may be an issue for you and discuss it with your health care provider.

Prevention, as usual, is the best medicine.

Monday, February 16, 2009

Plastic People

"Anything you can do I can do better. I can do anything better than you." This comes from the musical Annie Get Your Gun and the way some of us train you'd think that it's true.

Following an average or sub par race performance, the tendency might be to pour it on in an attempt to improve. Instead of ending up on the podium, they end up in my office. Hurt! Tendinitis, stress fractures, fractured family relationships...and no races. I see the same thing this time of year when those New Year's resolutions are beyond realistic.

Unbridled enthusiasm leads to more training errors than Stadler has flats on the Queen "K." Couple this to those unexpected "workouts" such as the 8 hour Boy Scout canoe trip or hike using muscles you forgot you had, shovelling out the little old lady down the street after a 15" snow fall or moving the offspring from one apartment to another and you have the recipe for overload.

We are no longer Plastic People as when we were kids, able to do just about anything we pleased without physical consequence. We know the difference between Advil and Tylenol from first hand experience. So what do we recommend to these athletes in order to stay away from the doctor? A plan.

To eliminate the speed bumps caused in exercise by overtraining, understanding that the sum work effort that each individual can handle is personal. Joe Friel of Training Bible is one of many who want you to follow these very easy steps: 1) Have a game plan, possibly covering a full year. 2)Write it down. it should include races you plan, family vacations, century rides, the works. 3) Weave your workouts and tapers around your planned contests. 4) BE REALISTIC about the training load your body sees and most importantly the rate of change in this load. Remember, just because one of your friends trains in a certain manner does not necessarily mean you should. One yardstick would be not to increase by more than 5% per week. Rest assured that as we age even that may be excessive. 5) Stick to your plan and build in rest, preferably a rest (decreased volume) week every 3-4 weeks. It's called periodization.

It's so much more rewarding to help an athlete avoid injury than to treat one, especially one that is self-induced.

Monday, February 9, 2009

We All Have Limitations

Not long ago, in my capacity as Medical Director of Training Bible, I received a question from a woman who had physical pain as a limiter to improving cycling speed. She was very dedicated to triathlon, so much so that despite significant low back pain, in order to continue competing she'd undergone multiple medical evaluations and treatments over the years, even to the point of back surgery. And pain was still a problem! Below is a summary of the advice I gave her as many of us find ourselves in a similat boat, particularly as we age and just can't do what we've always done in the past.

"You present a particularly difficult, but not uncommon situation: a strong desire to participate limited by physical constraint. A constraint that were it "fixable" it would have been done by now.

So , as Inspector Harry Callahan (Clint Eastwood) famously stated in the movie Magnum Force, "A man's got to know his limitations." We all have limitations. I've had many patients over the years address, define, and deal with musculoskeletal issues by doing to following: 1) honestly assess your potential given the current restrictions, 2) modify whatever it takes involving your bike, your stroke, etc., 3) then train/race within your personal parameters. We all know folks who used to run marathons or do 1/2 Ironman racing, but like you, are now physically limited.

Before paying a couple hundred bucks for a bike fit, we have our patients keep a very specific log for a month or two since you know your body better than any doctor or cycling specialist. I would write down specifically what hurts and make a change, possibly with my local bike shop guy whom I've come to know and trust. Seat up, seat down, bars higher, etc. Keep it for a week and then after your ride, before you even go in the house or take off your cleats, write down exactly what you feel. Same? Different? Better? Worse? WHERE? Now, make another change with the bike guy and do this again. Most notably, just because a friend has a certain aero position doesn't mean you need to. (In fact, with your back, maybe your aero bars belong in the closet.) So frequently what may feel comfortable on a trainer during a bike fit does not 30 minutes down the road. Look at Lance's time trial position, significantly higher and seemingly less aero than other TdF riders. But, it's comfortable for him and from it he can generate his maximal sustainable power. What works for you may be drastically different from others. Lastly, two ibuprofen before a ride have become a good friend to many (if ok with their doc.)"

Hopefully, this will help you follow the path to success.

Wednesday, February 4, 2009

Take Care, Achilles

"We run, not because we think it is doing us good, but because we enjoy it and cannot help ourselves." Sir Roger Bannister

Anybody in your running group out with achilles tendon problems? If not now, statistics would point toward the probability in the future as 8-10% of running related issues are achilles in nature. It's the strongest tendon in the body connecting the heel bone (calcaneus) to the calf musculature.

Achilles tendon pain may occur in any athlete, particularly those who may be deconditioned for the chosen activity, runners who do excessive hill work or the old "too much too soon"seen so often in my office. It starts gradually, 4-6 cm above the heel, as pain only with exercise subsiding with rest. Jumping sports like volleyball can accelerate the process, or when making a significant change to one's training plan. You do have a training plan, right? Even normal running can cause tiny tears in the tendon which heal spontaneously unless the runner over stresses the area with insufficient rest. Rest is KEY to the Training Bible athlete! Ultimately, this can lead to a chronic tendinitis picture with nodules in the tendon and in very rare cases, rupture of the tendon. I'll bet that would change one's training.

So, you think you might be getting it and want to know what to do. Well, before you call the doc, you'd try twice daily cold therapy-watch out for frostbite. Have a friend inspect your legs looking for redness or maybe a cracking feeling coming from the narrowest point of the tendon. It can be pretty dramatic. A heel lift from your local running shoe store can be beneficial-both sides if you've had limb length inequality issues. While there, ask them to look at your shoes and your gait. I have great respect for the local running shoe store owners and they can be an invaluable resource.

In summary: 1)back off your running volume/intensity
2)twice a day icing
3)careful stretching
4)short term heel lift (work shoes too)
5)see your local "running shoe guy" then Sports Med Specialist if not getting better quickly.