Sunday, May 29, 2011

Calf Strains

"I intend to live forever.   So far, so good!" Stephen Wright

Ironman finisher Pat McCann

Ironman finisher Mike Hemenway

Aside from being well dressed local business men, what do these two Ironman Finishers have in common?  They are both currently suffering from a calf strain.  In what's become an all too common story, both of these superb athletes have moved away from triathlon because of injury but stay active in other endeavors.  Pat trains daily with the area SEAL Team Training - yep, you've seen them in the park, lots of push ups and carrying logs around, you know the type (my type actually, so do I).  Mike has had a hip replacement and so his options are a bit more limited.  He bikes, walks and although he goes to the pool and says he's swimming, I'll be he spends more time talking to the life guards.

Successful, continuous running is all about balance. Only part of this, regardless of body habitus,  is the ability to glide down the track while others lunge, lurch or plod.  Paul Jagasich, a professor of modern languages at Hampden-Sydney College in Virginia, calls this working with the elements.  He successfully swam the English Channel in 1988 but had a very hard go of it somewhere near the middle because of the waves and rough seas.  He was struggling mightily with his environment...until he figured out the timing of the waves and how to stroke from wave top to wave top.  It was "dancing on the waves" as he later put it.

As runners, if our brains are constantly in gear considering our running surface, foot wear, environmental factors, previous running load/stress/effort, then hopefully we'll minimize the potential for injury.  In Born To Run, Christopher McDougall quotes the Sports Injury Bulletin, "Athletes whose sport involves running put enormous strain on their legs." The American Academy of Orthopedic Surgeons (of which I am a member) concluded that distance running is "an outrageous threat to the integrity of the knee."  We need to be on top of this every day so that we're concentrating on our running successes, not visits to PT as we make our daily log book entry.  We'll work with our elements.

Lets look at the pertinent anatomy of the calf.

The two main posterior muscles are the gastrocnemius, or gastrocs, and the soleus.  More superficial, the gastroc crosses both the knee and the ankle joints and aids in both knee flexion and ankle extension - toe down. The soleus is deeper and contributes to your ability to stand on your toes.

When evaluating the patient with calf soreness, some will report the acute onset of pain near the center of the calf, "Like I got hit there with a golf ball!"  Interestingly, others experience no sudden pain, only a localized soreness following exercise.  Rarely they can remember over stretching the muscles.  In the pre MRI days, this would have been classified as an injury to a tiny muscle deep in the calf called plantaris.  But, we now know that the origin of pain is the medial (inside) head of the gastroc and that once noted, if the activity continues a complete tear of the muscle may follow.  The athlete should be so warned.  (Other sources of calf pain including stress fracture, blood clots, etc. should be considered.) That said, most calf strains only involve a small portion of the gastroc.                                                        
musculotendinous junction

The junction between the gastrocnemius muscles and achilles tendon

A mild strain results in only a small amount of pain and/or limitation of exercise and is called a Grade 1 strain.  Grade 2 strain injuries are more involved and may be accompanied by swelling and bruising of the calf - often quite extensively!  They will be more painful and will limit most leaping, jumping or running sports.  At this point, the care giver will likely suggest rest without sports participation until pain free.  The athlete would prefer to heal this fully the first time and not suffer a recurrence. Gentle calf stretching (not to the point of pain) and icing will be recommended.  Support hose often assists in resolution of the swelling.  Once the triathlete returns to sport, heat before participation may be beneficial.  Services of a Physical Therapist/Athletic Trainer may also speed the recovery with ultrasound and massage, and don't forget about the benefits of Ibuprofen.  Casting may play a role occasionally.

Lastly, a Grade 3 strain can include a greater involvement of the muscle to the point of rupture, an inability to walk or contract the muscles, and significant swelling/bruising.  These are frequently repaired.

Usually a Grade 1 injury resolves in 10 days, Grade 2, 4 - 6 weeks and a grade three 3-6 months.  There have been reports of some permanent weakness after these.  Fortunately, the Grade 1's and 2's are the most common.

And, in the words of General Patton, "Success is how high you bounce when you hit the bottom."  I suspect that this can be said about more than triathlon.

Happy Memorial Day to all.  Thank a veteran!

Sesamoiditis Update  - I did a blog a while back on Sesamoiditis, pain under the ball of the foot, and recently found an interesting cause. One athlete, without trauma, was having the gradual onset of pain and after working this through, we determined that it's source was a recent bike fit!  He had a habit of riding with his right knee closer to the top tube than the neutral position.  The bike fitter put a wedge between the shoe and cleat but all it did was overload the medial foot.  Thus...sesamoid pain!  Wedge removed, pain gone, happy athlete...trying to "remember" to keep his limb neutralized.

Images 3, 4, 5, 6 Google Images

Saturday, May 21, 2011

Eating Disorder Awareness

Happy Mother's Day

"There once lived a man named Oedipus Rex.  Oedipus had a very odd complex, but he loved his mother."   Tom Lehrer

This was originally scheduled for Mother's Day but for a couple reasons I decided to delay it.  In the long term it really won't make much of a difference because this is a pretty important topic.

A mother and daughter waiting for their triathlon  'teammate. '

Eating Disorder Awareness

While touring colleges with our daughter last week, I found this posted in on the wall of the infirmary of a mid west university:

                                                            Staggering Facts...

  • 54% of women would rather be hit by a truck than be fat (Martin, 2007)
  • If mannequins were women, they would not be able to bear children.
  • Research shows that just 3-5 minutes of engaging in fat talk substantially increases body dissatisfaction (Stice, 2003)
  • Four out of ten Americans either suffered or have known someone who has suffered an eating disorder (NEDA, 2005)
  • As many as 20 million females are battling an eating disorder such as bulimia or anorexia. Millions more are battling binge eating. (Crowther, J. H., et al. 1992)
  • Most fashion models are thinner than 98% of most women.
  • 81% of ten year olds are afraid of being fat (Martin, 2007)
  • 25% of American men and 45% of American women are on a diet on any given day (Smolak, L., 1996)
While I cannot speak for the reproducibility of these "statistics" you get the point.  Eating disorders are serious business and triathletes are neither excluded nor immune. Even celebrities like Paula Abdul, Justine Bateman, Karen Carpenter, Susan Dey, Tracey Gold, Princess Di, and Joan Rivers have experienced an eating disorder.  EDs have the highest mortality of any of the mental illnesses.  In fact, 20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart disease.  But, according to the South Carolina Dept of Mental Health only one person in ten with an eating disorder ever receives treatment.

If you're reading this blog it's because you're interested in triathlon performance.  Compiling a complete piece on eating disorders is beyond the scope of this blog but suffice it to say that it's a serious issue with endurance athletes and will have a negative influence on their performance.

Casa Palmora is a clinic in California that specializes in those patients with ED.  In their advertising they point toward a number of famous athletes who've suffered with eating irregularities including 9 time Olympic Gold Medalist Nadia Comenechi and Bahne Rabe, a winner of 8 Olympic Gold Medals in rowing who also suffered from anorexia which would ultimately contribute to his early death.

Others you'd know include tennis player Zina Garrison, skater Nancy Kerrigan, jockey Laffit Pincay, gymnast Cathy Johnson, etc.  A quick check of PubMed notes a study by DiGioacchmo et al. of 583 triathletes  where 39% of the females and 23% of the males scored below the mid point on a standardized test to construct Calorie Control.  "All of the subjects indicated dissatisfaction with their body mass index (BMI). The study participants revealed attempts to reduce body weight by means of energy restriction, severe limitation of food groups and excessive exercise...  The triathlon seems to be a sport that is susceptible to a higher prevalence of disordered eating." 

Nancy Clark, RD says that, "Athletes with eating disorders tend to be very talented, hardworking people who ache inside and fail to see their strengths.  Something inside them says they should always be working or studying or exercising.  Taking time to hang out and chat with others makes them feel guilty.  They need to learn being "human" - like the  rest of us - is more attainable than being "perfect."
So whether you are talking bulimia, anorexia, etc. they can be both treated and prevented.  We define eating disorder generally as an "obsession with food and weight that harm a person's well being."  The cause is incompletely understood, and although initially it may start with a preoccupation with food and weight, this is a multifaceted affliction. Societal pressure for "thin is in" or "you can never be too thin or too tan," excess stress or needing to have the feeling of being "in control" all contribute.

We already know that in addition to diminished athletic performance, physical problems can effect the heart, kidneys, GI tract, and lead to menstrual irregularities as well as dry, scaly skin.

For the person with an eating disorder, accepting the fact that treatment is in order may the single hardest step.  Occasionally inpatient hospitalization is required.  Significant counseling of the patient, spouse and family can all contribute to the potential for success.  The Internet is rife with help like the National Eating Disorder Association whose sole goal is to aid those in need by specialized, individually oriented care hopefully pointing to a successful outcome.  They are careful to address both the medical and nutritional components as well as assisting in securing insurance company coverage when needed.

In summary, this is a common, destructive disorder and if this blog leads to just one person seeking assistance, it will be my most successful writing to date.  Help a friend!

Credits:  NEDA
              Google images
              Denison University Health and Counseling Center

Sunday, May 15, 2011

Colonoscopy And The Triathlete


A man went in for a colonoscopy.  The gastroenterologist examined him, and then turned him on his side to begin the procedure.  The doc immediately noticed a large piece of lettuce protruding from the gentleman's posterior.  "Sir", she said, "did you know that you have lettuce hanging out of your bottom?"

"Yes," replied the man, "but that's just the tip of the iceberg."

Jill Triathlete, a prominent local real estate attorney, was at her Primary Care Physicians office recently for a cold which just refused to go away. Jill thought she might have pneumonia from that Saturday long run in the cold and rain. Fortunately, after the evaluation, it was a relief to find out she didn’t. The doctor was idly thumbing through her chart and when she settled on the Health Maintenance page she noted, “Jill, you’re 50 and you haven’t had your screening colonoscopy.” Jill’s mind went ablaze with thoughts. “Colonoscopy? Put something where the sun don’t shine? Take a ride on the black stallion? The snake? OMG…if I can just get to the Delorean quickly enough to activate the flux capacitor…..” yet she replies a cool, “Oh, really?”

Colonoscopy really isn’t such a big deal these days. Most are done under sedation although there are those who, potentially not so wisely, think, “If I can finish an Ironman without sedation, I can sure as heck fire do one these little tests without it. “ But they’re not always correct….as they find out in short order.

It’s the prep that gets folks. And it’s not that it hurts or anything, it’s just inconvenient and their body does things that under ordinary circumstances would be considered very abnormal. The day before the procedure goes something like this:

Hearty Breakfast – 2 cups of tea, no milk or cream,
Lumberjack’s lunch – as much beef bouillon as you wish
PM Snack – either tea or bouillon, take your choice
Supper – Dulcolax pills and this delightful beverage called Miralax, as in laxative. It’s the same plastic jug that you buy a gallon of milk in, but looks, and tastes, like Secretariat’s urine. Only worse. The good news is that there’s a whole lot it.

Now is the time one learns the definition of explosive diarrhea. Leaving the house is not an option. Leaving the sight of the commode may not be an option either. Think garden hose velocity liquid coming out of you. But (butt) think of it this way, you’re getting your innards spic and span so that if there’s anything of interest, your gastroenterologist can see it quickly.


The Colon Cancer Foundation describes the procedure as follows:
Colonoscopy (koh-luh-NAH-skuh-pee) lets the physician look inside your entire large intestine, from the lowest part, the rectum, all the way up through the colon to the lower end of the small intestine. The procedure is used to look for early signs of cancer in the colon and rectum. It is also used to diagnose the causes of unexplained changes in bowel habits. Colonoscopy enables the physician to see inflamed tissue, abnormal growths, ulcers, and bleeding.

After your IV's been started and sedation given, the doctor will ask you to lay on your left side and he/she will insert the scope, a flexible tube with a light at then end and video capabilities projecting the image on a screen that you and the doctor can watch simultaneously.  As the scope gets further into the colon, air can be passed through it to inflate the colon making both vision and scope passage easier.  The whole procedure lasts about half an hour, sometimes a little longer when something out of the ordinary is discovered by the examiner.

You will recover there and in an hour or two, and when most of sedation has worn off you can leave.  Most do not find it an unpleasant experience and occasionally they give you the photos from "down inside." I wouldn't suggest putting them in your Christmas cards, however.

In short, a great deal of information can be obtained in a short period of .  Processes, once considered fatal, can be located and treated early, often without surgery.  Make sure you say thanks to the doc.  With a little luck, you won't have to do this again for 10 years.

Workout of the Week
One day this week in the pool try this for a main set.  After your usual warm up, pick an interval, say :45sec/50 yards and do the following.
Swim 100y on 1:30, 50y on :50 then 50y on 1:30 (to catch your breath), repeat 3 times - total 800y.  We did this one on Friday and it's a good push.

The gent next to me in lane 5 swam 100 yds, jumped out of the pool and did 10 push ups, then hopped back in the water, all under 2:00 min.  Repeat 10 times. Total work out time 20:00.

Credits for the above: Patricia Raymond, MD
                                  Colon Cancer Foundation

Sunday, May 8, 2011

Morel-Lavallee Lesion - Soft Tissue Trauma On The Bike


Joe Friel passed on a very interesting letter from a skilled bike racing physician in St. Louis, Madeleine D. Kraus, MD.  She'd suffered a bike crash while racing, much like many of us have sustained, but with a very different outcome.  She's given us permission to edit and print the letter.  So, thinking that all of us can learn from her misfortune, here goes:

Some injuries look worse than they are. Road rash is, in my opinion,
the prime example. A gooey mess that will frighten the children, but
using only what you have at home you can effect a complete recovery.
There are other injuries that are worse than they look. These are
the ones that the cyclist should have very forward in their mind after
a crash. There may be no evidence of their existence for hours or
days, the critical window during which an intervention may reduce or
eliminate complications. A subdural hematoma after a blow to the head
with loss of consciousness is one example and pneumothorax after a
blow to the chest with rib fractures is another. I suspect that a
trauma surgeon could come up with a better list than this, but I can
at least add a third since I now have personal experience with it.

The Morel-Lavallee lesion/hematoma, or “closed de-gloving injury”
is a delayed massive hematoma of the thigh that seems to me to fall
into the same category. The key features are that the crash involves
a (1) “high energy” (i.e. high speed) impact in which there is (2) a
tangential blow to (3) a part of the body in which there is a broad
fascial plane covering muscle. All the small blood vessels that feed
the skin and subcutaneous tissues over the fascial plane are sheared
in half and begin to leak blood and serum slowly into the space
between the fascia and the subcutaneous tissue. The side of the
thigh is the most common site, and the bleeding will not stop until
compression is applied across the whole thigh (either intrinsic
compression through massive swelling or an extrinsic pressure
compression bandage). An ER doc might not consider the possibility
of a Morel-Lavallee’s lesion/hematoma when presented with a cyclist
for reasons that I will mention at the end.

How I acquired first hand experience with this complication of racing
is as follows:

During a race I took too much speed into the inside of a turn in a
road race in which the only line I had was into gravel and a
pothole, and came off with a thump and a long skid. The Garmin read
27.8mph before coming abruptly to 0mph. I got up, put my chain back
on and was fixing the shifter and derailleur when the wheel truck
came by and the driver asked about my well being. I gave the thumbs
up and a smile and they drove on. The elbow of my long sleeve
jersey and the side of my tights were somewhat disrupted but there
was no road rash, and my head, arms, and legs were working fine. In
short, there was nothing to lead me to believe I had sustained the
start of a clinically significant bleed, and it seemed quite
reasonable for me to continue in the race. The fact that I had been
in the break and at least wanted to avoid being caught by the pack
may have overridden certain reality checks, but I do not think so.

After the finish, my legs were fine. I based that thought on the fact that I
finished only three minutes behind the winner and on what a quick
check of the Garmin told me, that I had ridden the last half of the
race quite well.. As it turns out this is NOT a
good criteria for concluding that there was no leg injury.

My hip and thigh felt just as if there was nothing more than a bruise of the usual type
developing. The only cue that this was more than minor, perhaps,
was that the ragged surface disruption on my tights ran all the way
from the hip to just above the knee – the only evidence that there
was a broad tangential blow to the lateral thigh. That escaped
everyone’s attention.

When I woke the morning after the race, my AM HR was 10 points
higher than usual, but even then it was hard to see the asymmetry in
thigh size that was developing. By the afternoon, however, the
visible evidence of bruising from hip to knee became evident. The
next morning (2 days after the race) I checked my hematocrit - blood level - and
found that it had dropped 6% from the level it had been at two weeks
before (I work in a hospital and have easy access to such laboratory
testing). Two units of blood!! It was too late to do anything about
it, but at that point that I knew I had had a slow but clinically
significant bleed into my thigh.

At its peak the thigh hematoma was 30 x 20 x 10cm in size. Though it
is shrinking now, a pseudocapsule (the Morel Lavallee’s lesion) has
developed, and it will not go away. It will have to be surgically
removed. If a compression bandage had been applied at that first
visit, it might have mitigated or avoided entirely this outcome.

What can be learned from this? You need a high index of suspicion
for such an injury, and the ability to get a compression bandage
applied before the signs and symptoms of the full blown Morel-
Lavalee hematoma are evident. This is a challenge since I suspect
that the Morel-Lavallee is underrecognzied in cyclists because (1)
it does not restrict function initially – e.g. does not prevent
finishing a race or ride with speed/power equal to pre-crash
speed/power – and is not visibly obvious for many hours, (2) it
does not produce symptoms initially – either the cyclist has no
other injury that would compel an ER visit, or they do go the ER and
a more significant injury elsewhere gets all
the attention, (3) in the mind of the examining physician it might
not fulfill the criterion of “high energy” / “high speed” impact –
at least some trauma surgeons and ER docs may have in mind the
recreational cyclist puttering along bike paths at 10-12mph, not the
race paces that create the high energy impact necessary for this
type of injury to develop. And in some settings, even when speed is
reported, I think there is some suspicion that some might assume it
is an exaggeration, particularly if the patient is a woman.

So ,simply being aware of some possibilities may allow us to ask better
 questions and make us better patients when we have to assume that role.
I offer this story as an example of that.


Thanks Madeleine for bringing this to our attention and raising our index of suspicion next time we smash our thighs during a bike crash.   Good luck to you in eventual complete resolution of your problem.

image credit: Google images