Friday, May 28, 2010

Been Stung by a Jellyfish?

"The guy sure looks like plant food to me." Audrey II, Little Shop of Horrors

Many of us have run into a jellyfish or two either training or racing in ocean water. More of an inconvenience than anything for most of us, some poor souls have a more significant reaction. I answered a questioner this week who stated a jellyfish sting allergy and she wondered about the legality of wetsuits in an important ocean swim she has in her future, I suppose thinking the wetsuit a shield of sorts.

Well, her race is Ironman Hawaii where wetsuits are not permitted. I've been stung in Kailua Bay a number of times, but it's always more like little needles that hurt/itch a little that day and then, like most of us anyway, it's gone. I've never even seen the ones that got me. If you're lucky, and looking ahead while you swim, which I know most of us don't do, and there's a big Portuguese man-o-war ahead, you can try and swim around it. Remember, it's tentacles can be 5-8 feet in length and have 100's of stinging cells on each. It's not uncommon after a stinging that some swimmers experience nausea, headache, muscle pain, etc., and after the initial welts subside they're left with permanent scars.

In some locations, primarily around Australia, some jellyfish stings are so powerful that those who encounter them may need hospitalization with intravenous anti venom without which they suffer respiratory failure and and die quickly.

So, if this summer you are stung by one, first (with gloves) peel off any left over tentacles and apply vinegar, straight from the kitchen. More involved stings may require medical attention and support from a cardiopulmonary perspective. And, always be aware of the signs of an allergic reaction - difficulty swallowing/breathing/swelling, etc.

And how do we advise our lady with jellyfish allergy? Well, first, I told her to contact the race director and race medical team well before the event. They need to know of the possibilities here. Second, there's a high likelihood that she can be "premedicated" before the race such that should a stinging event occur that she's covered. Sadly, in this day and age, I wouldn't be surprised if a special document isn't drawn up for her signature noting the risks she faces and accepts. Hey, it's 2010.

Saturday, May 22, 2010

Golfer's Elbow - Time for Platelet Rich Plasma?

These guys have no elbows. For the inaugural Ironman race on Oahu in 1978, Navy Commander John Collins made the winners trophy in his basement. It became known as the "Hole in the Head" for a couple obvious reasons, among them it's appearance and, perhaps describing anyone who'd do the 140.6 miles! 8" miniatures were given to each finisher of the 25th Anniversary Ironman in 2003. A cool thing to do for sure.

I was recently asked about tendinitis over the inside or medial aspect of the elbow. In Orthopedic circles this is known as Golfer's Elbow.

Golfers elbow - or medial epicondylitis - is pain at/near the muscle origin over the inside of the elbow. Sort of like tennis elbow but on the opposite side of the elbow and less frequent. It seems to occur in men more than women, dominant over non-dominant arm. Although pain is the predominant complaint, people will sometimes note forearm or hand weakness, numbness radiating into the hand, usually little finger and ring like when you hit your funny bone. I've had some folks complain of a just plain stiff elbow.

You'd like to know why you "got" it. Was it overuse or repetition of placing the elbow in an overloaded state or was it a single forceful episode that over taxed the muscular origin? The diagnosis is usually made by your story and findings on physical exam. Often x-rays are obtained to look for arthritis, missed trauma, etc. Very rarely will someone think about an MRI.

In any event, the right things to start with include strapping, NSAIDs, etc. I've had very good success with PT/Occupational Therapists who've gotten the patient to be absolutely anal about stretching and icing among other things.

Failure of the above, in my office, gets a corticosteroid injection as they just seem to work. Maybe even two, over time. Here the literature gets a little cloudy. As has been noted here before, Orthopedic Surgeons (and I'm one of them) are quick to jump on a passing bandwagon. PRP is basically your own blood placed in a centrifuge. The clear part, or plasma, is where this high concentration of platelets is extracted and subsequently injected in the area of chronic tendinopathy. It makes sense. But it's still new enough that there are few long term studies on which we can base treatment on science, not intuition. A NY Times editorial earlier this year quoted two studies where it had been injected in elbows - one helped more than standard treatment, one didn't. Also, and this is important, many insurers will not pay for it. And it can get right expensive! So, the jury is still out on PRP but I think, ultimately it will have a role. But not as first line treatment. We just don't know what that role is. Yet.

Very occasionally a surgical procedure will be needed but in most people's hands, only after failure of an extensive conservative effort.

Sunday, May 16, 2010

Triathlete with Enlarged Heart - Abnormal?

"The heart is the first feature of working minds." Frank Lloyd Wright

We see frequent headlines noting the very premature death of young athletes with pathologic cardiac conditions, the so-called enlarged heart also known as hypertrophic or dilated cardiomyopathy. It's been proposed that athletes participating in multiple endurance events like iron distance racing or a high number of marathons induce subtle changes, which, over time, can lead to significant changes in cardiac function. Negative changes!

To answer this question, researchers tested Olympic level athletes using EKGs, echocardiograms, etc., over a 9 year period and found little correlation to the extremes of training intensities/volumes to any cardiac difficulties.

In the article by Levine, et al, they summarize these findings stating, "...the report goes a long way to reassure the medical community of the inherently physiologic and clinically benign nature of prolonged and intense endurance training."

So, when we see high profile athletes like Ironman Hawaii Champion Greg Welch with well publicized heart problems, don't blame the training per se but look for a different explanation. Keep up your own training. But/if you have anything like chest pain, jaw pain, etc., don't just blow it off, ask someone who knows. Better safe than sorry.

Sunday, May 9, 2010

Pressure to Exceed Your Tri Capabilities

Pre-race bike inspection. Everyone is still smiling.

"Superman where are you now? Phil Collins, Land of Confusion

Mark Foley is a local Veterinarian and a strong biker. His wife PR'd at the Boston Marathon a couple weeks ago. Their kids are into all kinds of sports. They work up gradually to the endurance sports they choose and are usually successful.

At a lecture in January, noted Triathlon Coach Joe Friel began to compare the running boom of the 80's to the growth of triathlon today. (If you'd been told ten years ago that someone would pay $40,000.00 to get a slot at Ironman Hawaii, you'd thought them clearly insane. Yet, we find ourselves in the middle of the annual Ironman auction which puts up 4 entries to the race to the highest bidder/donator as the money goes to the Ironman Foundation. This branch of IM donates a significant sum each year to a host of deserving Kona organizations like the rescue squad, various help agencies, etc. Check out to follow the progress of the last two slots.)

Joe's story went something like this. In the 80's, folks would have a friend convince them to go jogging, like it, and progress to running, and strange things would happen. It might start out with a local 5K race, they'd get "hooked" and after smoking too much Runners World Magazine, they're convinced they can begin marathon training. And some can. Their life becomes consumed with running and a myriad of details until they find themselves running the first 10 miles of a 26.2 mile experience. All goes well until mile 18, when they find themselves with shot quads, over heated, and out of ideas.

Compare the above scenario to triathlon where it seems easy to tackle the local sprint tri, maybe even an Olympic distance race...and then you start to dream...and a friend of a friend is doing IM Lake Placid...and, "With just a little more training, I could be an Ironman." Maybe.

But what happens when our hero gets to mile 95 on the bike, is beat, rethinking how aggressive she might have been over the first 56 miles, would like to call it a day but she's not even off the bike - and there's some running to do...? As Mark Foley says, "You have to have a plan B; alternatives."

In other words, it's OK to stop at a bike aid station and sit in a real chair while taking on fluids for 15-30 minutes. It's OK to ask the medical people for a little help, they're not going to take you out of the race unless you're a danger to yourself or others. It's OK to walk. Well, it's ALWAYS OK TO WALK. Or to sit at a run aid station to collect your wits. Or even every 5th run aid station if that's what it takes.

You have a full 17 hours to finish this thing. If you've thought these potential problems through ahead of time, then during the press of the event where folks don't always make the best of decisions, you'll not decide something in haste that you'll come to regret.

Just think about it.

Monday, May 3, 2010

Chronic Plantar Faciitis/ Mumuku, the Wind That Blows Both Ways

Puako is situated on the northwest coast of the Big Island of Hawaii. It is the home of one of the largest petroglyph (carvings in the lava) fields in the Hawaiian Islands. Found there are figures that are unmistakably those of the ancient Hawaiian warrior - the Alapa. Legend has it that, because of the intense heat and winds, this was an ideal training ground to harden these warriors making them Hawaii's toughest and finest. Generally, the trade winds in the morning blow from the north, and as the volcanic soil heats up, the wind shifts around to the south.

This is especially important to would-be Ironman competitors as, after a crisp 2.4 mile swim in the Pacific with 1800 other racers with arms and legs flailing every which way in a scene more reminiscent of a washing machine than a swimming race, they mount their bikes and head north 55 miles to the coastal town of Hawi - you guessed it, into the wind. Unfortunately, by the time they reach this northern turnaround point, the land has heated sufficiently to reverse the winds, thus the bikers experience a headwind both ways - Mumuku! The locals think it's cute.

Plantar Faciitis - heel pain. It grabs many multi sport athletes and runners. The usual location is the bottom of the foot back at the heel where a large band of tissue, the plantar fascia originates. It's said that over 2,000,000 of us a year will experience symptoms of PF but that with a little care, it will resolve in most in 6 - 10 months. During the symptomatic phase, reduction/elimination of weight bearing activity (running) has been traditionally recommended along with ice (rolling your arch/heel over a frozen water bottle for 15-20 minutes), rest and stretching. Treating the area as a trigger point has also shown to be of benefit with the use of massage balls. The athlete will cross train during this period but frequently great patience will be required.

A study in the Journal of Bone and Joint Surgery by Baumhauer et al. in 2006 (volume 88-A, Number 8) studied a group of 88 patients with chronic PF, dividing them into two groups. The first group was give a PF stretching program and the second an Achilles stretching program. (pretty sneaky!) "Substantial differences were noted in favor of the group managed with the PF stretching program." After 8 weeks, the group with the Achilles stretching program were changed over to the PF technique and they, too, achieved excellent success. "Fifty-one patients (77%) reported no limitation in recreational activity, and 62 (94%) reported a decrease in pain," at the study's end.

The PF stretch is performed by crossing the affected leg over the other placing the fingers at the base of the toes pulling them back toward the knee until a stretch or pull is felt in the arch or heel. Evaluation of one's running footwear, stride mechanics, running surfaces and mechanics, etc. at this time will serve the athlete well long term.