Sunday, March 27, 2011

Osteoporosis - Part Two
Kona Pier During Tsunami
 Tsunami in Kona

For those of you who didn't see the photos from Kona making the rounds the day of the earthquake in Japan and subsequent tsunami, this is Kona Bay where the swim portion of the Ironman starts and finishes.  The green tents to the right mark the location of the women's changing tent during the race.  I'll bet your time for T1 would be a might slow here. (I believe credit for the photo goes to Bob Babbitt and Coffees of Hawaii.)  For an absolutely insane video during the tsunami - taken by a candidate for the Darwin Award according to IMH Transition Coordinator Mike McCurdy, check out this video on Youtube .


"Were lavish to the bone,"  Freddie Mercury, Queen

"What a dog I got.  His favorite in my arm!"  Rodney Dangerfield

For those of you who read last weeks blog, we discussed the definition of osteoporosis, risk factors, etc. and that it's not just a disease of elderly women.  In fact, one fifth of all hip fractures occur in men. Although men start with a higher bone density and are not subject to menopause (even if it's hard to tell the way some guys act occasionally) both sexes are subject to this process.


First, the diagnosis of  osteopenia (less bone) is made when there is a diminished amount of bone but not yet enough to be considered osteoporosis.  Bone density cannot be measured, or even semi-accurately guessed at on regular X-rays.  We normally use a test called a DXA (Dual-energy X-ray absorbtiometry) a type of X-ray.  It uses two X-ray beams of different energy to allow subtraction of the soft tissue and subsequent determination of bone mineral density.  It is NOT a bone scan which so many of you have had to rule in/out a stress fracture.

The World Health Organization recommends a  DXA in :
     1)  All women over 65, men over 70.
     2)  Women under 65 who have additional risks:
              - estrogen deficiency
              - a history of maternal hip fracture
              - low body mass (less than 127 lbs.)
              - a history of amenorrhea (absent or diminished periods) more than a year before age 42
      3) And, there are 12 other less common subclasses recommended

A standard exam in an adult is a scan of the lumbar spine and either or both hips.  These results can be compared to a young adult reference population (Z scores) or to an age matched population (T scores) to calculate future fracture risk.  In other words, the knowledge that one is osteopenic is crucial in slowing or halting the progression to osteoporosis.

In response to Osteoporosis Part One, a commenter noted, "I routinely ask my new running/coaching clients (mostly women) to get screened....and am on about an 80% 'Gotcha' rate for catching anemia, very low vitamin D levels or both.  It's pretty stunning to me."

One condition that bears brief mention here is Transient Osteoporosis of the Hip, a process of unknown etiology noted by the acute onset of new hip pain with X-ray evidence of osteoporosis and an MRI indicative of inflammation of the bone itself. It resolves on it's own in 6 - 12 months with the short term goals of pain control and fracture prevention.  These patients are often placed on a walker or crutches.  Although uncommon, it's seen in pregnant women after the sixth month and in males aged 40 - 70.


In some sports, it's said that the best offense is a good defense.  It's no truer than here. Once bone is lost, it's difficult to replace.  If, while we're young, we're commited to a diet rich in calcium and vitamin D, maintain a dedication to exercise - a major portion of which is weight bearing - and pay attention to a healthy diet, we'll reduce the potential of developing osteoporosis.

Should we find ourselves facing the diagnosis of osteoporosis we may be required to take medication to strengthen the bone.  Unfortuntely, as noted above, one is frequently symptomless until a fragility fracture brings the diagnosis to our attention.

So, for today:  1) Know the recommended daily amount of calcium and vitamin D for your age, sex, etc.
                       2) Understand that sunlight is a major contributor of our vitamin D and that we may have
                            different dietary needs in winter versus summer.
                       3) Maintain a life long commitment to exercise and a healthy diet.

The finish line in Kona after the tsunami. (same credit)


Sunday, March 20, 2011

Osteoporosis -Maybe You Have It But Don't Know It

Evel Knievel
"I forgot all of the things that I have broke."  Evel Knievel

In this weeks mail bag was a note from Katie, a "30 year old female Ironman. "I live, eat, breathe, ...sleep triathlon."  She's being worked up by her physician for what could be her second stress fracture, was diagnosed with Achilles Tendinitis, and has tested sero-positive for rheumatoid arthritis.  She hasn't had a period in over a year and admits, "Basically I'm a walking mess."

Kills you doesn't it?  Here's a nice gal who wants to strut her Ironman stuff but because of injury she's unable to.  You already know that a stress fracture is progressive failure of a previously healthy bone, frequently caused by overuse or a marked increase in one's exercise regimen.  They're quite common in the bones of the lower extremity especially in bone whose previously normal strength is diminished by osteoporosis.  A good example would be the 2nd metatarsal seen in the x-ray below (2nd metatarsal - long bone second from left.)

According to the National Osteoporosis Foundation, "About 10 million Americans already have the disease and 34 million are at risk."  They go on to suggest that about half of all women over 50 will break a bone because of osteoporosis.  And the kicker, one in four men will too.

Although white, bones are not like chalk or cement.  They are quite alive.  In addition to holding us up they provide a large reservoir of calcium for it's myriad of functions out side of bone.  Healthy bones are always changing, remodeling, responding to the ever-changing load or stress applied.  (Too much stress...stress fracture!)  As we age, or in Katie's case be subject to other issues as well, the mineral density of bone naturally decreases.  In some it can lead to osteoporosis.

If you check out the Mayo Clinic web site for stress fracture and osteoporosis risk factors, you'll find the expected overlap. For SF's:
    1)"...more common in track and field...
    2)...often occur in people...who rapidly change the intensity, duration or frequency of training sessions.
    3)sex.  Women who have abnormal or absent menstrual periods are at higher risk.
    4)...weakened bones.  Conditions such as osteoporosis can weaken your bones..." Orthopedics separates risk factors for osteoporosis into:

Things you can't control
    Female sex
    Family history of osteoporosis
    Early menopause (including surgical removal of ovaries)
    Thyroid or parathyroid disease
    Low testosterone (in men)

Things you can control
    Excessive alcohol consumption
    Poor diet
    Inadequate calcium or vitamin D intake
    Sedentary lifestyle (not an issue with this crowd!)
    Decreased weight

    Some seizure medications
    Oral steroids like Prednisone
    Some types of chemotherapy or immunosuppression

We're very used to being given a long list of warning signs for most diseases but the problem here is that there may not be any until we suffer a low energy fracture - a break with minimal force.  This would be in contrast to, say, a broken nose, which many of us have suffered.  Like a quote attributed to boxer Leon Spinx after his 3rd or 4th broken nose, "At least I still got my good looks."

Next week we'll finish this up discussing:
    1) Tests to diagnose osteoporosis
    2) Transient osteoporosis of the hip
    3) Various treatment options - predicting the future
    4) Advice for Katie and all the Katies out there.

First, second and fourth images - Google images

Friday, March 11, 2011

I Have A Pulse Of 213!!

"Food" For Thought

Tachycardia (Rapid heart beat) follow up - I wrote a piece here December 13, 2010 and would like to report on a recent athlete. A couple days ago, Joe Friel asked me about an athlete who was concerned about a heart rate of 213 ( So much for the 220 minus your age concept!) on his Garmin. It actually felt higher to him. His previously observed max was 195 from some ferocious 5K finishes. A smarter than average gent, he'd already ruled out external sources of electrical interference, checked to ensure proper chest strap placement and moist leads, etc. He slowed to a walk, watched the rate slow to below 200....and finished the race.

Let's work this through together.

Although our first reaction is to write this off to some sort of artifact, he has every chance that this was real. Although he'd already made the appointment to see his doctor, he asked for our opinion and got pretty much what was previously written concerning A-fib, SVT, etc.  Joe threw in some info regarding viral myocarditis. When our athlete asked about going ahead with a planned race on Saturday, we advised him against that until after he had seen his family physician.

What do you think he did? Ran? Didn't run? What would you do?

He ran (of course, he thinks like you do)..."but just did it as a training run." Only he knows if it was the right thing. If I get more information I'll report it.

Why this isn't a heart attack - To do it's job of providing blood to a triathlete's hard working muscles, the heart muscle needs it's own supply of blood carrying oxygen. Over time, the coronary arteries will often have plaque deposited on their inner wall making them more narrow and reducing the flow of blood. As you've heard on tv, cholesterol plays a significant role here. Once the blood flow is reduced below a critical level, the muscle of the heart, starved for oxygen, begins to die...a heart attack.

Platelet-Rich Plasma injection follow up (3/1/2010 blog)- I came across an article from the American Journal of Sports Medicine February, 2011. "This study does not support the use of Platelet-Rich Plasma... to repair of small or medium rotator cuffs tears to improve the healing..." 

But, to be fair, there are a host of supporters of this technique (many anecdotal) and we will continue to follow it.

More, Food For Thought (??) Speaking of heart attacks

Last two images from Google


Friday, March 4, 2011

PRP Injections, Is One In Your Future?


Platelet Rich Plasma

Life's been good to me so far."  Joe Walsh

While college hunting with our youngest last week, we spent time in central Pennsylvania Amish country not far from the boyhood home of Floyd Landis.   Floyd was raised a Mennonite.  These are strong people who have a belief and value system and they stick to it in the face of pressure from a more modern society; not unlike being a triathlete from time to time.  You can certainly disagree with some of the choices Floyd made but you have to agree that he's one tough hombre on a bike.*

Floyd won the 2006 Tour de France but was later disqualified and removed from the Phonak racing team after both testing positive for synthetic testosterone and having an abnormally high epitestosterone/testosterone ratio.  Normally this  is 4:1 but Floyd's was 12:1.  Landis vehemently pronounced his innocence but later testing of the total 8 samples he gave during the whole ot the 2006 TdF revealed 4 to be positive for synthetic testosterone.   His excuses became so implausible that even David Letterman came up with a "Top 10 Floyd Landis Excuses."


When thinking about Floyd and blood doping, which he finally admitted to, I was reminded of another use of blood,  platelet rich plasma injections.   In my 2/5/2011 blog, I covered cortisone injections which can be used for a variety of musculoskeletal conditions including arthritis, bursitis, tendinitis, etc. and now comes PRP which some say is the way of the future for overuse injuries. PRP has been around for years as it's been shown to help patients undergoing lumbar spine fusion.  But, it's application to the athletic world is relatively new. It's risen to national attention primarily secondary to its use in professional athletes.   The concentration of platelets is 4 -5 times the normal amount depending upon the centifugation technique used once the blood is drawn (from a vein in the arm just like having your blood count checked.)  It's been shown to increase the levels of certain growth factors once injected.  But, and this is a big but, it's not yet known over the long haul if this type of injection makes a difference in resolving the tendinitis for which it was intended.

As noted before, in the marketing world, triathletes are part of a group known as early adopters.  In other words, when there's a new or different running shoe, compression hose, aero bike, or injection technique, they'd be expected to be among the first to try it.  And again, although some reports of PRP are promising, and  it seems to make sense, long term we're unsure if it's superior to current techniques. 

In our community,  very few physicians perform PRP.  It can be pretty pricey at nearly $1000/injection - or more - in some cases and you'd want to check with your insurer pre-injection to see if it's a covered service or you could be eating Ramen noodles for the foreseeable future...and without that new pair of compression hose!


*Weird Al has his own take on this - "Party like it's 1699" .
Images from Google Images