Monday, August 30, 2010

Workout Guilt, Of Course You Have It

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

Triathlon training takes a long time. (Duh, many of you say.) This is especially true when preparing for the longer distance events. There's only so much you can do squeezing training in and around your schedule before you have to do the same to their schedule whether "they" is wife, husband, kids, co-workers, etc. Frequently we find ourselves battling that inner demon who tells us that we need 30 more minutes on this run but our soul tells us to go home and relieve the baby sitter.

I was rereading John L. Parker, Jr.'s "Once a Runner" this week and thought a page spoke directly to this. I'm sure you've all read this wonderful text - if not go to and order a copy right now - but wanted to refresh your thought processes reminding us that endurance athletes have had to vault this hurdle for ages.

Here are fictional runner Quenton Cassidy's thoughts on the subject while tubing down the Ichetucknee River with his girlfriend Andrea:

"In order to arrange this day of perfect drifting, an entirely traditional local pastime, he and Mizner - now floating up ahead with his date - had arisen at 7:30 and run seventeen miles. It was the only way they could spend their day in the sweet haze of Boone's Farm apple wine and still appease the great white Calendar God whose slighted or empty squares would surely turn up someday to torment the quilt-ridden runner. They went through such contortions occasionally to prove to themselves that their lives didn't have to be so abnormal, but the process usually just ended up accentuating the fact. There were several ways it could be done. If they were going to the beach, they might put it off and run when they got there, but contrary to popular opinion, beach running is only jolly fun for the first five miles or so. After that, the cute little waves become redundant, the sand reflects the sun up into the eyes blindingly, grains of sand slip annoyingly into the heel of the shoe or flip up on the back of the leg. Fifteen hot miles on a long, flat beach sounds like good sport only to those who haven't actually done it. Also, the ocean is too infinite: the run seems as if it will never end.

They could always put off training until they got back in the evening, but that just made things worse. No beer! None of the sticky wine! Their friends would slyly tempt them, to see if they really took all that training stuff seriously. It was too much to ask. Better to get it all over with and then be able to enjoy the day like any other citizen."

Any of this sound familiar in your life. I'm bettin' the answer's yes.

Wednesday, August 25, 2010

Arthroscopy For Arthritis, When Is It Appropriate?

"I'll take any risk to turn back the hands of time." Styx

Triathlon covers all walks of life and all age groups. It's addictive, and it's cumulative training, plus getting older, can have deleterious effects on the body. Why do we see fewer and fewer folks in the older age groups? It's not 'cause they're busy playing Mahjong at the Senior Center. As we begin to "wear out" arthritis can become part of the picture and we reach for the cure so we can continue training and racing.

When the knees start to go (and we're not talking about the patient with some type of inflammatory arthritis here), many remedies can be recommended and be helpful including rest, or decreased training load anyway. Some variety of braces or sleeves are often of benefit. Therapy of one form or another with oral meds and injections have been known to be helpful in specific cases. And what about surgery?

We have become so accustomed to it that more than once I've had a patient refer to arthroscopy of the knee as "band-aid surgery." Honestly. They have no more respect for undergoing and anesthetic and surgical procedure with all of the attendant potential risks and complications than that. Please, only consider surgery when non-surgical means have been exhausted and the benefits outweigh the risks for you.

So which patients with a deteriorating knee can a scope help? Primarily those with some type of mechanical symptom, catching, snapping, locking, that sort of thing. Being under 50 helps as does normal alignment, not smoking, not being over weight, shorter duration of symptoms, and hopefully minimal changes on x-ray. These are standing, weight bearing x-rays taken of both knees to compare the painful and non-painful knees. We're not talking about an MRI here.

I taught a course to about 200 Primary Care physicians last month in SC and one of the take home points I tried to leave them with was that "The single most common x-ray taken in my office is the weight bearing view of the knees." We also talked about the fact that the patient needs to go into this type of procedure with open eyes and realistic expectations. Following arthroscopy, many surgeons give their patients the intra-operative photographs of the knee so they can have a visual reference to understand what they're dealing with and what the future holds for them.

So, if you are considering a scope to "clean out the knee/knees at the end of the season to get ready for 2011," make sure you've had the correct x-rays and have gone through the options carefully with your surgeon. Good luck.

Tuesday, August 17, 2010

Baker's Cyst

Got a lump on the back of your knee? Somebody mention Baker's Cyst or popliteal cyst? Although it may be news to you, these are more common than many people suspect. While not normally an isolated finding, there are two bursae (bursas) in the back of the knee joint which can fill with fluid. Even though it feels like a mass, and when we think mass we think cancer and these have nothing to do with cancer. Most commonly these are a secondary process in reaction to something going on in the knee joint itself. They are neither life nor limb threatening but can be quite bothersome. They are not the result of an infection. People who have them will report that some days they're large, some small, and while intermittently painful, the patient can actually be symptom free for much of the time.

The mass or fullness is actually fluid that has filled the cyst, much the consistency of the normal fluid found in a human joint. Often times they will accompany arthritis in the older patient and, although less frequently, a torn knee cartilage (meniscus) in the young.

If one is diagnosed with this problem, a number of options will be discussed and one of them is simply to do nothing. Many patients, once they discover that it's not cancer, will choose this option. Others prefer an aspiration of the cyst and injection of a steroid preparation. If still symptomatic to the point where, if a potentially treatable issue is uncovered, the next step might include plain x-rays and follow up MRI. These might be stepping stones to arthroscopy. In the patient with enough arthritis, and an accompanying Baker's Cyst,to warrant a knee replacement simply replacing the joint (not so simple for either patient or surgeon) will lead to resolution of the cyst.

Lastly, very infrequently, no other causative agent can be located and the patient will request excision of the cyst. This is pretty rare in my experience.

So, if your doc tells you that you have a Baker's Cyst, there's no rush to do anything, analyze your options and after weighing the risks/benefits choose what's best for you. Patience is always helpful.

Tuesday, August 10, 2010

Elbow Pain, Medial Epicondylitis

I took a walk around the world to ease my troubled mind. I left my body lying somewhere in the sands of time.”
Kryptonite, 3 Doors Down

Your thoughts when injured?

We frequently think of overuse injuries as running related but swimming can also take it’s toll. Swim training/racing can put us at risk for a multitude of upper extremity difficulties. We frequently see problems with the rotator cuff stealing the headlines, particularly in overhead throwing sports, while less commonly the elbow is involved. Many of us have either heard about or experienced Tennis Elbow (pain over the outside of the elbow or Lateral Epicondylitis, less often from playing tennis than from an alternate source despite its moniker.) Triathletes are more prone to Medial Epicondylitis – pain over the inside of the elbow. This is known in the literature as Golfer’s Elbow. You might be able to guess why.

Place your hand on the “bump” over the inside of the elbow, the medial epicondyle. It serves to anchor a host of muscular elements which flex the wrist and fingers. Also, just behind this bony prominence lies the ulnar nerve, a vital structure which provides the nerve supply for much of the strength and sensory in the hand.

Medial Epicondylitis occurs in an overload situation from many etiologies including raking, shoveling, house or garden work, any activity that repeatedly flexes the wrist. Sometimes with greater frequency or force than it’s used to. In triathlon, the causes can be much more subtle and one needs to be aware of this to resolve the pain.

Consider the complexity of the swim stroke as it aims to generate power against the water’s considerable resistance. Hand entry and exit into and out of the water are simply the end result of a long musculoskeletal chain, each element of which can have a major role in its resultant accuracy. Alter just one of these links in the chain, head position and corresponding body depth, body roll and its effect on finger entry into the water, etc. and it’s pretty easy to see why elbow problems can be secondary to subtle changes in ones stroke. It’s also important to note that both neophyte and veteran swimmers are susceptible. For example, consider the experienced swimmer who has a little shoulder stiffness after helping a child move from home to college. If the shoulder range of motion is decreased slightly, a subconscious alteration of some other part of the stroke may develop to compensate and voila, medial elbow pain at the conclusion of the work out which only gets worse during subsequent swims.

Thus, like many other overuse entities the cure involves resting the offending elbow, perhaps ramping up kicking and drills until it dissipates, carefully thinking about other aspects of life that put a strain on the joint with the goal of temporary elimination. There may be a role for non-steroidal anti inflammatory type drugs on a short term basis and I really push icing. If one is careful of the skin, 3 or 4 time per day icing can really calm these down and be done almost anywhere. A strengthening program one the pain has decreased can help most everyone can be found at many of the medical/injury websites.

But, unlike many injury situations, the athlete more than the medical community, will have to carefully consider the training changes, or outside training, that may have taken place to both stop the current complaints and prevent their recurrence. Once accomplished, it’s back to swimming as usual and typical goal oriented triathlete behavior. Happy training!

Monday, August 2, 2010

Knee Collateral Ligament Injuries

"...fate comes at you cat-footed, unavoidable, and bloodthirsty." Pat Conroy, South of Broad

We hear a lot about knee ligament injuries, especially when they happen to someone else. But when it's our knee that's out of commission from falling off the bike while still clipped in, or twisted water skiing at the lake, it's a different matter. The ACL or anterior cruciate ligament gets a lot of press. Bode Miller, Tom Brady, Tiger Woods. But the collateral ligaments (Tom Brady again) seem to take a back seat here. One reason could be that they usually heal without a lot of fuss so maybe less notoriety as well.

There are two collateral ligaments per knee, one on the outside from the head of the fibula up to the femur, the lateral collateral. And, on the inside, from femur to tibia, the more frequently involved medial collateral known as the MCL. ACL/MCL injuries are more common than you'd think, and frequently accompanied by a tear of one or both menisci (knee cartilages.)

The simplest grading system involves the degree of laxity or slack in the ligament post injury. 0 - 5mm is a grade 1 tear, usually an intra-substance injury in which the structure is slightly elongated but not ruptured. Grade 2 damage is noted when there's 6 - 10mm of laxity, a partial tear, and a grade 3 diagnosis involves 11 - 15mm, frequently a rupture or full thickness tear. A grade three injury can often coexist with other major ligament problems as seen above, and is the most likely to take a ride in the MRI machine.

Unlike some orthopedic maladies, suffering an MCL tear does not necessarily end one's season. In particular a grade 1 or 2 injury would rarely if ever be subjected to surgery and will heal on their own if given the right environment. (An environment that wouldn't include biking as you might have guessed.) But, grade 1 folks can almost immediately swim or exercise bike, resumption of full training coming in a couple weeks when virtually pain free.

The athlete incurring a grade 2 MCL isn't much worse off after a period of bracing and immobilization. The unfortunate biker with a grade 3 rupture, however, is a horse of a different color with a much longer period of immobilization, permanent expected laxity of, say 5 mm - something they get told the day the diagnosis, and it could be 3 months before they get to work out at 100% effort. And again, the potential for accompanying other structural abnormality is calculable with grade 3 damage.

So, should you or a family member be diagnosed with a collateral ligament tear, follow the protocol you're given, don't return to sport until you've been given the OK by the doc, and a high percentage of you will recover completely. It's fate.

Always say thank you to the volunteers ...and the police.