Saturday, April 30, 2011

Cinco de Mayo


Every once in a while I think it's important to pause and have something light.  I don't know the source of this but with Cinco de Mayo this week thought we could all use a smile. This is really funny!

Texas Chili Cook Off

Notes from an inexperienced Chili taster named Frank, who was visiting Texas from the East Coast:

Recently I was honored to be selected as an outstanding famous celebrity in Texas, to be a judge at a Chili cook-off, because no one else wanted to do it. Also the original person called in sick at the last moment, and I happened to be standing there at the judge's table asking for directions to the beer wagon when the call came. I was assured by the other two judges (Native Texans) that the chili wouldn't be all that spicy, and besides, they told me that I could have free beer during the tasting. So I accepted.

Here are the scorecards from the event:


JUDGE ONE: A little to heavy on tomato. Amusing kick.

JUDGE TWO: Nice, smooth tomato flavour. Very mild.

FRANK: Holy S***, what the hell is this stuff? You could remove dried paint from your driveway with this stuff. I needed two beers to put the flames out. Hope that's the worst one. Those Texans are crazy.


JUDGE ONE: Smokey, with a hint of pork. Slight Jalapeno tang.

JUDGE TWO: Exciting BBQ flavour. Needs more peppers to be taken seriously.

FRANK: Keep this out of reach of children! I'm not sure what I am supposed to taste besides pain. I had to wave of two people who wanted to give me the Heimlich manuver. They had to walkie-talkie in three extra beers when they saw the look on my face.


JUDGE ONE: Excellent firehouse chili! Great kick. Needs more beans.

JUDGE TWO: A beanless chili. A bit salty. Good use of red peppers.

FRANK: Call the EPA, I've located a uranium spill. My nose feels like I have been snorting Drano. Everyone knows the routine by now. Barmaid pounded me on the back; now my backbone is in the front part of my chest. I'm getting big time drunk.


JUDGE ONE: Black Bean chili with almost no spice. Disappointing.

JUDGE TWO: Hint of lime in the black beans. Good side dish for fish or other mild foods. Not much of a chili.

FRANK: I felt something scraping across my tongue, but was unable to taste it. Sally, the barmaid, was standing behind me with fresh refills; that 300 lb broad is starting to look HOT, just like this nuclear-waste I'm eating.


JUDGE ONE: Meaty, strong chili. Cayenne peppers freshly ground, adding considerable kick. Very impressive.

JUDGE TWO: Chili using shredded beef; could use more tomato. Must admit the cayenne peppers make a strong statement.

FRANK: My ears are ringing, and I can no linger focus my eyes. I farted and four people behind me needed paramedics. The contestant seemed offended when I told her that her chili had given me brain damage. Sally saved my tongue from bleeding by pouring beer directly from a pitcher onto it. It really pisses me off that the other judges asked me to stop screaming. Freakin' Rednecks! ! !


JUDGE ONE: Thin yet bold vegetarian variety chili. Good balance of spice and peppers.

JUDGE TWO: The best yet. Aggressive use of peppers, onions and garlic.

FRANK: My intestines are now a straight pipe filled with gaseous, sulphuric flames. No one seems inclined to stand behind me except that sexy Sally. I need to wipe my butt with a snow cone!


JUDGE ONE: A mediocre chili with too much reliance on canned peppers.

JUDGE TWO: Ho Hum. Tastes as if the chef literally threw in a can of chili peppers at the last moment. I should note that I am worried about Judge # 3.

FRANK: You could put a #)$^@#*&! Grenade in my mouth, pull the #)$^@#*&! pin, and I wouldn't feel a damn thing. I've lost the sight in one eye, and the world sounds like it is made of rushing water. My shirt is covered with chili, which slid unnoticed out of my X*$(@#^&$ mouth. My pants are full of lava-like poop, to match my X*$(@#^&$ shirt. At least the during the autopsy they'll know what killed me. I've decided to stop breathing, it's too painful. I'm not getting any oxygen anyway. If I need air, I'll just suck it in through the four inch hole in my stomach.


JUDGE ONE: A perfect ending. This is a nice blend chili, safe for all; not too bold, but spicy enough to declare its existence.

JUDGE TWO: This final entry is a good balanced chili, neither mild now hot. Sorry to see that most of it was lost when Judge # 3 passed out, fell and pulled the chili pot on top of himself. Not sure if he's going to make it. Poor Yank.

FRANK: - - - - - Mama?- - - (Editor's Note: Judge # 3 was unable to report).

Arthritis of the Spine

We've had a couple of good discussions about arthritis and osteoporosis recently.  I got a very nice note from a not so old triathlete, veteran of 6 IM's, with an xray noting some arthritis of his spine - but no symptoms - and this was the response:

Bryan - Hi. I'm John Post, MD, Medical Director of Training Bible and Joe Friel's asked me to see I can help out here. I see where you've told Joe about being 42 with mild arthritis of your back. If you were in my office right now looking at those x-rays, I'd probably tell you to put them behind you and get back to training. You could get 100 people from your high school class, none with any back complaints, x-ray them, and a good percentage would look exactly like yours. They'd be lawyers, plumbers, stay at home moms, everything and their lives would not be compromised by an x-ray. It's also pretty hard to credit one's performance to these films.

Lastly, a lot of folks would say that 6 IMs might be enough for some folks, more than enough with regard to bodily wear and tear, and that if you stepped back to sprints and oly's - and the reduced training commitment, think of all the time you'd have left over to go to your daughters soccer games, poker games on Friday night or do things around the house to be nice to your wife. After all, there's only 7 days till Mother's Day. Just a thought. Good luck.


The take home message here is that occasionally we can have a test result that, while abnormal, isn't relevant to the symptoms one might be experiencing.

Monday, April 25, 2011

Skin Cancer - You're At Risk

"And I love to live so pleasantly,
  live this life of luxury,
  lazing on a summer afternoon,
  in the summertime." The Kinks

Ah, the summertime - triathlon season - and the summer sun. The SUN.

First, some facts:
  • Skin cancer is the most common form of cancer in the United States.  More than 3.5 million skin cancers in over two million people are diagnosed annually.
  • Each year there are more new cases of skin cancer than the combined incidence of cancers of the breast, prostate, lung and colon.
  • One in five Americans will develop skin cancer in the course of a lifetime.
  • The incidence of many common cancers is falling, but the incidence of melanoma continues to rise at a rate faster than that of any of the seven most common cancers.  Between 1992 and 2004, melanoma incidence increased 45% or 3.1% annually.
  • Women aged 39 and under have a higher probability of developing melanoma than any other cancer except breast cancer.
Regarding indoor tanning:

  • Ultraviolet radiation (UVR) is a proven human carcinogen.  Currently tanning beds are regulated by the FDA as Class 1 medical devices, the same designation given elastic bandages and tongue depressors.
  • The International Agency for Research on Cancer, an affiliate of the World Health Organization, includes ultraviolet (UV) tanning devices in it's group 1, a list of the most dangerous cancer-causing substances.  Group 1 also includes agents such as plutonium, cigarettes and solar UV radiation.
  • On an average day more than one million Americans use tanning salons.
71% of tanning salon patrons are girls and women aged 16 - 29.
                                                       (Source: Skin Cancer Foundation)

Let's start with the basics.  It's estimated that 10,000,000 of us have at least one precancerous lesion known as an actinic keratosis, a scaly or crusty area commonly seen on ones ears, scalp or face.  It's not uncommon
to find them on the shoulders or neck, hands and forearms, anywhere that the sun has access.  Initially, they can be so small that you don't see them, you feel them.  And, what makes them more difficult to diagnose is that they can disappear, only to reappear later.  The incidence is higher in men as they tend to spend more time in the sun and use less sun protection than women do.  Many AK's remain benign but a number go on to become squamous cell carcinoma and can be life threatening.


Basal cell carcinoma is the most common of all cancers affecting 2,000,000 Americans each year.  Like the AK's above, they are also the result of sun exposure and are easily treated when diagnosed early.  But, they can be relatively aggressive and when treatment is delayed and prove quite disfiguring.  They can be treated with simple curetage or surgery, freezing, or what's known as Moh's micrographic surgery which can result in up to a 98% cure.  Rarely are they life threatening.

Melanoma is the most serious form of skin cancer secondary to it's potential to metastasize - spread to other organs in the body. Frequently, a change in an area of skin pigment, mole or simply just a dark spot can herald a melanoma.  The diagnosis is made by biopsy. If positive, the patient is returned to the operatory when one of the options is what's known as wide excision, a procedure that removes a generous amount of skin in the area with hopes of completely eliminating the cancerous tissue.  Unfortunately for the patient with melanoma, even such an excision will not guarantee against metastatic spread even decades later.

So, the take home lesson here is to understand that despite the fact that we are rough, tough triathletes, we are still susceptible to sun-induced skin cancer.  Broad brimmed hats and tightly woven clothing along with waterproof or water resistant SPF 30 or high sunscreen are the order of the day.  It just takes a minute and is not a sign of weakness.  And, perhaps most importantly, anytime there's a change in the appearance of your skin bring it to the attention of your family doc.  You'll be glad you did.

Sunday, April 17, 2011

Peroneal Tendon Problems

Albert Einstein "The difference between genius and stupidity is that genius has it's limits."   Albert Einstein

My 3/14/09 blog covered tears and rupture of the Posterior Tibial Tendon, potentially a career ending injury, and it generated a great deal of interest.  To this day it is one of my most researched posts.  Today I'd like to shift our attention to the outside of the ankle and the very important peroneal tendons.


Problems with these two structures, the Peroneus Longus and Peroneus Brevis, can be significant but are often over looked by examiners as the source of lateral ankle pain.  Because of their frequency, when the athlete complains of lateral ankle pain, they are so often lumped in with those who've suffered a sprain and diagnosed as same.  The consideration of alternative diagnoses is missed.  It is this pair of tendons which function in everting the ankle (raising the 5th toe side) like when you get off your bike just before the foot contacts the ground, as well as aiding in joint stabilization in the mid stance phase of running.                                                                              

Note prominence of Peroneal Tendons in eversion.

Together, the tendons course just behind the lateral malleolus, the fibular head, over the outside of the ankle and are maintained in this location by a pair of stout ligaments as well as a groove in the posterior aspect of the bone in most of us. Interestingly, about a fifth of us have a small bone in the substance of the peroneus longus which, to the untrained eye, could resemble a loose fragment of bone in the joint on x-ray. 

Problems with the Peroneals

As you might guess, inflammation (tendinitis or tenosynovits) from over use is most common in the athletic population.  You'd find pain, swelling and point specific tenderness just posterior to the head of the fibula.  This can also occur in trauma involving the lateral ankle.  If needed, an MRI scan could differentiate between this and the more serious tendon tears either partial or complete.

Many things can lead to an actual tendon tear in addition to previous tenosynovitis as some patients have reported multiple previous ankle sprains or chronic lateral ankle pain.  Although as a general rule, you'd like to avoid surgery whenever possible, this is a hard area to get to heal spontaneously.  Most of these end up in the OR.  If a simple longitudinal tear is found, it can be debrided and closed.  But, it's not uncommon to find an extensive tear which requires not only debridement but tenodesis as well, a procedure in which the bad tendon is sutured to the remaining good one.  Infrequently both tendons are torn increasing the degree of difficulty of the repair as well as lowering the expected outcome.  There can be a long term loss of function of the foot.

One other issue merits discussion here and that's subluxation or dislocation of the tendons.  These can be acute or chronic and are generally seen in an athletic population.  These folks complain of a snapping sensation in the lateral ankle and can frequently duplicate it by rotating the joint.  If it's an acute finding, casting can be beneficial (with the tendons reduced to their normal location).  In the patient with chronic subluxation, casting often fails leading to a surgical procedure.


Although relatively uncommon, injury to the peroneals occurs often enough that it should be part of the thought process of medical personnel involved in the care of triathletes who complain of lateral ankle pain.  The next step, while occasionally conservative, often follows the path to a surgical procedure.

Underpants Run in Kona

"Be who you are and say what you feel because those who mind don't matter and those who matter don't mind."  Dr. Seuss

Lastly, I got a nice note from Nancy Roberts asking me to alert you to her personal blog.   It seems informative and well written.

Images 1, 2, and 3 - Google images                                   


Saturday, April 9, 2011

Patellar Tendinitis


" He had the gifted athlete's innate sense of timing, a sense of providence, of fantasy, an intuition in to the art of the the Proper Moment, where the escape velocity of frivolous lunacy triumphs over the gravity of every day life." John L. Parker, Jr.  Once a Runner

Selene Yeager (USA Cycling certified coach - Bicycling Magazine) points out  in There's a Tweak For That Twinge that "achy hinges are usually a result of incorrect saddle height/or cleat position, weak outer glutes, and doing too much too soon, especially in a big gear."  I'd tend to agree.

We've previously discussed a number of knee issues including arthritis, meniscus tears, arthroscopy and microfracture just to name a few.  This week we're concerned about the patellar tendon which attaches the bottom edge of the knee cap to the tibia - shin bone. It's a very strong tendon that very rarely ruptures but in it's role as part of the extensor mechanism of the knee, together with the patella and quadriceps, straightens the knee.  This can be hill climbing on that bike, at foot strike on the run or in the pool with a kick board in your hands.

If we over do it, and as triathletes there's lots of ways to over do it, the para-tenon, the very thin but highly vascular tissue that surrounds
the tendon becomes inflamed and painful. This inflammatory condition is called patellar tendinitis. As you might imagine, the patellar tendon is commonly over stressed in jumping sports and has picked up the nick name of "Jumper's Knee."  Jumper's knee is different from tendinitis in that it's actual injury to the tendon, so-called tendinopathy, and the painful area is right at the bottom of the knee cap. It can be hard to distinguish between the two.  You'd expect tendinitis to involve the whole of the tendon making pain distribution over a wider area. (If you read up on this further you'll find many sources will combine both the terms and pathology making differentiation confusing.)

Andy Pruitt, in the Complete Medical Guide for Cyclists adds that, "The tendon might squeak like a rusty hinge when you bend your knee.  This worrisome noise means that the tendons normal lubrication is in short supply."

If we have patellar tendon based pain, we'd expect the examiner to elicit pain with direct pressure on the tendon and occasionally observe swelling.  " a little grape at the end of your patella," says Pruitt.  There can be times when your doc feels  that an MRI is in order to look
for damage to the tendon.

The single best cure for patellar tendinitis is a four letter word.  You got it, rest.  Rest means only the lightest of riding or stopping riding altogether for a period of time. This can be a hard pill for the driven, type A, "I always follow my work out schedule," triathlete.  If it truly is tendinitis and there's no tendinopathy, this is an opportunity to see if that bike fit is correct, if you're pushing overly hard on hills, etc., the issues at the outset of this article. For most, the lower the severity of the problem the quicker the return to sport. There can be a role for NSAIDs like ibuprofen and icing. I've had some success with both cross friction massage and strengthening of the quads and the calves.
However, if true damage is present (tendinopathy) you may be looking at formal PT and ultrasound and surgery in the rarest of cases.  This is one of those problems that's best caught early like so many things. And, with an accurate diagnosis comes accurate care.
Good Luck.

PS - if anyone knows how to get in touch with author John L. Parker, Jr., I'm looking to get a signed book for a graduation present.  E-mail me at [email protected] - thanks.

image credits: 1)
                     2) and 3) Google images

Saturday, April 2, 2011

Caffeine - Where Do We Stand? Legal Performance Enhancer?

Do You "Pre-race Dope" With Caffeine?  Why Not?

"You know my temperature's risin', the juke box's blowing a fuse.
A heart's beatin' rhythm and my soul keeps a singin' the blues."  Roll Over Beethoven, Chuck Berry

Food For Thought

Caffeine - Your Legal Drug

We've learned a lot about caffeine over the years. Heck, when you consider the caffeine I've consumed so far today without even thinking about it, you'd have to include the coffee I had before breakfast, iced tea with lunch and Diet Coke afterwards.  Don't forget my fave, the Hersey's dark chocolate kisses. If perchance I'd had a headache and taken a couple Excedrin, there's more caffeine there than the a.m. coffee. But, you wouldn't find any in the Gatorade I had after working out.  The Gatorade web site points out, "Currently, caffeine has no place in Gatorade products.  There is no convincing scientific data that shows caffeine can consistently and safely enhance the performance of athletes in a wide variety of situations.  Caffeine is a stimulant and many sports medicine professionals have concerns about athletes over-consuming caffeine."  As a big company (with a legal division) you'd expect such a carefully worded statement in that they have no control over who consumes the product or how.

Matt Fitzgerald, author of Racing Weight, How To Get Lean For Peak Performance says that, "Caffeine is the most widely used drug in the world.  Despite the negative connotations of the word drug, however, caffeine is by and large a benign and even beneficial substance for humans."

It first came to my attention in medical school when David Costill a pioneering member of an early group of physician/runners who wanted to measure, to quantify running, to make it more precise, published early work on the benefits of caffeine to the running population. As a caffeine user (some would say addict) I was asked for a post-race sample of my blood at the finish line in Hawaii to measure the caffeine level a few years back also.  If you think about the number of products in our daily lives that are laced with the stuff, it's a sizable list.  Think Jolt Cola and Five Hour Energy Drink, think weight loss aids and over the counter pain meds, think chocolate and many ice creams.

OK, so we know it improves performance and your level of alertness but there are a few negatives to keep in mind.  As a stimulant it can raise both your heart rate (see blog 3/11/2011) and blood pressure to a degree.  As a slight diuretic, it may increase urination, potentially increasing your risk of dehydration and it's detriment to performance.  Know anyone with "the shakes" in the office from that one too many cups of morning coffee?  And, don't forget the insomnia for some who have coffee/ tea/etc. after supper.

What is also known is the beneficial effects of this drug are much less in those who are already habitual users.  If they double the dose on race morning, it may help a little but the non-consumer will get more of a boost.  I've seen it written that if daily users also want the positive kick from caffeine that we should cut our intake for the week preceding the event and then "pop some" on race morning.  A 70 kg athlete would consume about 400 mg 30 -60 minutes before the gun.  The effects last around 5 hours and some athletes I know will "re-dose" in T2 of an iron distance race.  However, at least once source suggests limiting caffeine to 500 mg per day.  Occasionally, the habitual user who suddenly reduces consumption may experience some element of caffeine withdrawal.

Fitzgerald has also noted that pre-exercise caffeine, particularly in the non-user, will diminish post-exercise muscle soreness up to 50%.

So what do I recommend?
     A)  decaf the week before and 400 mg as you finish setting up your transition area, or
     B)  decaf always except in specific situations, the long drive, expected muscle soreness following a
           planned work out, or pre-race.

"The best part of waking up is Folgers in.................."