Thursday, June 30, 2011

EPO, Worth the Risk? Separate Lab Values for Athletes?

"Make friends with pain and you'll never be alone."
                                     Ken Chlouber, Creator of the the Leadville Trail 100
EPO.  Ever used it?  Think it will make you faster?  Increase your hemoglobin/hematocrit, oxygen carrying capacity, that sort of thing?  As you might imagine, I get a lot of letters with medical questions.  One recent questioner's note deserves discussion as, when discussing his own blood level, he stated, "I have a hematocrit of 51.  I think it's normal, I looked it up."  I politely disagreed. 

I was told recently that I would be amazed at the number of age groupers who'd experimented with some kind of performance enhancing agent be it EPO (erythropoitin alpha), Adderall (the combination of dextroamphetamine and amphetamine used in attention deficit hyperactivity disorder), or any of the steroid or growth hormone products that we see pro athletes accused of on a routine basis.  I couldn't believe it and still have a hard time comprehending it now.  How could winning a fifty cent medal, competing for the most part against a group of people you don't know, be so important that you don't give it the same thoughtful consideration you do for your kid's school issues or the interest rate on your home mortgage? 

Just to be clear, EPO (Epogen) is normally produced by the body in the kidneys and it stimulates the bone marrow to produce more of the oxygen carrying red blood cells.  It's one of the agents that pro cyclists are accused of injecting to increase their gross number of red cells, their hematocrit.  There are a number of problems with this:

  • EPO increases the rate of DVT, blood clots in the legs, which can break off, travel up the venous system to the heart/lungs leading to an increased risk of death .  The primary docs liken it to sludging when the blood actually thickens.*
  • Patients given EPO as part of their treatment are at "Greater risk for death and serious cardiovascular target higher versus lower hemoglobin two studies."  In other words, we as athletes would be at a higher level of risk than patients with a lower blood count.*
  •  EPO "...shortened overall some clinical studies..."* 
In short, it just doesn't make any sense for one of us to take this drug.  Perhaps the best we can hope for is the highest blood level that our bodies can manufacture without being pushed.  Ensure that you get enough iron in your diet, not always easy for our meatless friends.  Keep going to the blood bank to donate blood in the off season as not only are you helping others but it's been shown that the body will make just a little more blood than it needs to - sort of like natural blood doping. A rebound phenomenon.

Short History Lesson   30 years ago there was very little regulation of transfusions.  For example, if you'd recently undergone a CABG (coronary artery bypass) your surgeon could give you blood anytime he/she felt like it.  Then along came AIDS and the playing field changed.  Limitations were placed on transfusions where, unless you had a documented hematocrit below 33, you were not permitted to transfuse the patient, even if the patient had pre-donated their own blood.  Sometime later the level was dropped to 31, then 29, etc., all with the intent to only give patients what they absolutely needed.

This takes us to laboratory values.  At our hospital, the normal range of hematocrits is 35 - 47.  But, everyone of you who've donated blood, or had a significant bleeding episode of one cause or another, and then gone out on Sunday with the usual bike group, knows that you are sucking wind big time when it comes to climbing!  It's said that losing one unit of blood, approximately 10% of your blood volume, only drops the hematocrit by 3-4 points.  But it makes a difference for sure.  You can still be in the normal range but have very abnormal performance.

But, is this true of all lab values?  Should we as athletes have different normals simply because we're athletes?  A piece in one of the tri mags presented that opinion recently.  That as endurance athletes we have different normals than the gal next door. But I was unable to find support for that position after interviewing the head of Pathology of our hospital (in charge of all the blood tests, urine specimens, path reports, etc.) nor from Pathology of the University Teaching Hospital.  I looked in my copy of the running bible The Lore of Running by Tim Noakes and was not able to find mention of a difference.  For example, if the standards for serum sodium are 135 - 145, would an endurance athlete be higher or lower and how do you define endurance athlete?  One who does sprints but trains a great deal?  The Iron jock who may work out less but chooses a greater racing target?

The answer I was given by the Pathologist, a terrific biker who does the local hilly century ride in under 5 hours?  Normal is normal.

* Physicians Desk Reference

Sunday, June 26, 2011

Previous Knee Injury, Now Discovered Triathlon and......

"I had some dreams, but they were clouds in my coffee."

                                                                             Carly Simon

Summer Solstice: The triathletes dream day.   The most sunshine, warmth, unlimited training .   The only thing that could make it better would be if it were weekend day.
I've done two recent blogs on knee injuries and this is pretty typical of the query I've received in response.  Maybe this is you!

I tore my ACL and meniscus 20 years ago now and have had it repaired,
along with further keyhole surgery to clean out cartilage etc. Up until
a year ago I played a lot of competitive tennis and stayed away from
contact sports. Triathlon has become a bit of a salvation in last year
because it takes me away from so much lateral movement. However I am
approaching my running very tentatively and have not really improved by
10km race time by much during last season .......The question I have is can you recommend a book for running that caters
to someone like me i.e. history of a dodgy knee, working hard to
strengthen, very ambitious to make some great 10km times next season (and
hopefully run an IM at some point in the future,but needs to get the volume and
intensity of work just right, so as not to overdo it?

Hi George - I'm John Post, MD, Medical Director of Training Bible and Joe's forwarded your question on to me. I'm an Orthopedic Surgeon by trade and have reconstructed 100's of ACL tears and think I can help you with this issue.
First off, two of my last Training Bible blogs have been about ACL tears so your timing couldn't be better. Check 'em out. Also, I've gotten a couple other questions like yours so, using you as the good example, I'll try to share this in my next blog. In short, when people tear and ACL, or ACL and a meniscus, even if repaired by the best surgeon in the land, the knee is never quite normal. In other words, even though these two structures received surgical attention following your injury, you can bet that there's a significant probability that other ligaments in the knee were slightly stretched, or the joint lining articular cartilage had some measure of compression or shear damage as well. We currently quote patients 25 years, "and that's when you may start having problems" but this number is not based in hard science. Yet. And, each of us is different. I guess it's this difference that attracts us to triathlon.
So, as I see you now, I envision someone who is happy in the sport, one who gets great joy out of the competition and the work it takes to get to the start line, but wants to make a leap, perhaps a pretty big leap, in improvement. Sounds good. But, some folks in this group will get to some level in training duration, intensity, or both, and the knee starts to act up. And instead of following the dream, they have a seemingly endless list of problems and find difficulty just getting back to base line.
I'd suggest that if you are going to ramp up your training that you do so ridiculously slowly to see if you can't sneak up on this potential problem. I'd ask you to talk with your local sports guy, doesn't need to be an Orthopod, get some weight bearing xrays and a good evaluation to see if there's and discernible degeneration in the joint at this point in time. And then it comes back to you to make the decision that's best for you. (You might even get some benefit from coaching, as much to guide you as to hold you back on your ultimate pursuit. Sort of the "Easy Seabiscuit!" methodology.) In the end you'll make the best decision on the information you gain and I wish you a long and productive triathlon career. Good luck.

This is not new but it looks like a good time to give it some air.

Cyclists are the biggest sandbaggers and secret
trainers around. They'll say anything to soften you
up for the kill. Don't let this happen to you. Study
this handy rider's phrasebook to find out what they
really mean when they say:

"I'm out of shape"
Translation: I ride 400 miles a week and haven't
missed a day since the Ford administration. I replace
my 11-tooth cog more often than you wash your shorts.
My body fat percentage is lower than your mortgage

"I'm not into competition. I'm just riding to stay in
Translation: I will attack until you collapse in the
gutter, babbling and whimpering. I will win the line
sprint if I have to force you into oncoming traffic.
I will crest this hill first if I have to grab your
seat post and spray energy drink in your eyes.

"I'm on my beater bike"
Translation: I had this baby custom-made in Tuscany
using Titanium blessed by the Pope. I took it to a
wind tunnel and it disappeared. It weighs less than a
fart and costs more than a divorce.

"It's not that hilly"
Translation: This climb lasts longer than a
presidential campaign. Be careful on the steep
sections or you'll fall over -- backward. You have a
39x23 low gear? Here's the name of my knee surgeon.

"You're doing great, honey"
Translation: Yo, lard ass, I'd like to get home
before midnight. This is what you get for spending
the winter decorating and eating chocolate. I shoulda
married that cute Cat 1 racer when I had the chance.

"This is a no-drop ride"
Translation: I'll need an article of your clothing
for the search-and-rescue dogs.

"It's not that far"
Translation: Bring your passport

Thursday, June 23, 2011

3 Bikers, 3 Crashes, 3 Fractures

"I got the rockin' pneumonia, I need a shot of rhythm and blues"

                                                               Chuck Berry

Quick note - Caffeine - (From previous blog) I was asked by several about "shakiness" having dosed up on pre-race caffeine, and yes, you are correct.  In fact, I was jittery enough that pinning on my race number was a bit of a chore.

Bike riding is serious business and although we do it for fun, exercise and athletic improvement, all too often we see in this blog and other places that there's much that can happen astride a two wheeler.

In the last year or so, I've had 3 friends crash and I'd briefly like to share both the details of the incident so you don't let yourself get into the same predicament, and the results of their injuries.  We'll call these friends Moe, Larry and Curly although collectively they are far from stooges.

Over the Memorial Day holiday, we ran a thread on a tri forum dedicated to those who'd lost their lives while biking in training or racing and the length of the list is astonishing.

"Moe ' is a plaintiffs attorney who's qualified for Kona in the recent past.  He was riding his road bike down a fairly steep hill on a local dirt road which he knew well from having ridden both his mountain bike and road bike there in the past. While braking, his ram's horn handle bars became loose, rotated forward, and he lost his ability to brake.  He very quickly picked speed, crashed, and suffered a hip fracture like you might expect to see at the nursing home.

At surgery, the fracture was reduced, pinned, and he is now healed.  He had blood clots in his leg post op and had to have blood thinning medicine for 6 months.  Recently he finished the bike leg of an Ironman 70.3 race in 2:27, second by a minute in his age group.  Obviously he's a talented biker.

"Larry" was riding on a quiet hard surface road having just passed over a small rise.  Attempting to make a turn, he looked back to clear himself of traffic, but because of the small hill was unable to see a vehicle approaching at a rapid pace...and was struck by it going partially over the hood and windshield before striking the ground.  Hard!  He fractured two of the bones in his lumbar spine and had a "slight" nerve injury.

He was x-rayed, scanned and braced.  And although this is one tough hombre, he needed generous pain medicine, was out of work and most definitely off his bike for a couple months.  He's returned to finish our local end of summer century ride under 5 hours over a beautiful but hilly course.  He still has occasional back pain.

Lastly, "Curly" a former near National Champion duathlete, and one of the most careful riders I know, while riding in a populated area on a relatively busy street, had a driver suddenly open the door of a parked car.  And he rode right into it suffering a fractured pelvis in 4 places!

Following x-rays and scanning, he was quite fortunate that no other internal organ damage occurred and that surgery was not deemed necessary.  He was non-weight bearing on crutches until the pain dissipated, was eventually permitted to ride the trainer in his garage, and although now back to riding, has yet to return to his level of peak fitness.

What do these three riders have in common?  They were extremely fortunate that even though significantly injured, they're alive and making a good recovery.

Learn from these gents...don't be a stooge.

Images 2, 3, 4 from Google Images

Sunday, June 19, 2011

ACL Tears, Part Two

"The most important truth
is that knowledge is power,
knowledge is safety, and that
knowledge is happiness."

                                     Thomas Jefferson

I guess Tom saw the importance of reading this
blog, too.


Isn't it interesting that we should be discussing this injury, the same one suffered by Tiger Woods, the world's greatest golfer (but not SUV driver).  He very recently pulled out of a golf tournament and, more importantly, bypassed the U.S. Open Championship, a major event that he's won in the past, because of knee pain.  Serious stuff.

Caffeine Update: Not long ago we discussed the use of a "legal PED" or performance enhancing drug, caffeine.  It was pointed out that if one is a regular coffee drinker that abstention from the black gold for a period of time was important for the race day dose to be effective.

Well, I've learned over time that a good deal of what's written in magazines is a compilation of what's been written before with the author really having honest knowledge or experience with the subject that he/she is trying to give you advice on.  Water running is one of those topics that, in my mind having tried it many, many times with 30 years of intermittent triathlon injuries, is misrepresented in it's ability to get your heart rate anywhere near your training zones.  So, I tried what was written about caffeine.  And for me, the abstention was more than a week, closer to 3 weeks.  No coffee, no caffeinated sodas, tea, etc.  But, when you take your 400 or so mg an hour before the race, you know there's a change going on in your body.  Whether or not you race faster may be a different matter, just don't always believe what you read even if it's in a reputable magazine or web site that you trust.  The author's human too.

In the June 6th blog we discussed the anatomy and function of the anterior cruciate ligament, one of the most important structures in the musculoskeletal system.  This blog will cover the findings on physical exam, options for treatment including potential surgery and the post operative course.

Not all knee problems involve ligaments or surgery.

The triathlete being examined for consideration of an ACL tear will usually have a slightly warm, swollen and painful knee.   They know there's something wrong with it unlike any injury they may have suffered in the past.  At some point in the diagnostic chain someone will want to know if the swelling in the knee is blood or not, always a bad sign. This would be determined by aspirating the joint (putting a needle in.)  Various tests to determine the status of the ligament would be performed by the examiner, plain x-rays obtained to rule out fracture, and potentially an MRI to confirm the exam findings.  

Note on MRI's: too frequently, be it in the office or on a triathlon forum, the participant/patient's answer to knee pain, regardless of etiology or other information, "Well, let's get an MRI," as if they are free.  With a cost of anywhere between $750 and $2000 per scan perhaps judicious use of this valuable resource would be best in situations where other diagnostic tools have failed.

After the exam and studies are complete and the diagnosis of ACLT made one has to decide whether or not to reconstruct it.  Note this does not say repair because when this ligament ruptures it is not repairable. The low demand elderly patient might not be chosen as a candidate for surgery or those in which the rupture was a freak accident and the patient won't be stressing the joint in life or sport.  That said, I would imagine that most reading this are now and wish to remain athletically active and most likely will undergo some type of reconstructive procedure.  This is especially true to prevent later damage to other structures in the joint from giving way episodes in the future.  What is done and how it's done varies considerably on patient age, personal preferences and experience of the surgeon.

Generally this surgery is done arthroscopically as an outpatient and the recuperative period is approximately 5 - 6 months.  Lastly, it's important to remember that when this ligament tears, other parts of the knee are also injured although perhaps on a sub clinical level.  This would mean that even after the most perfect operation and rehab, the knee is neither the way it used to be nor normal.  There's an excellent chance that it will function quite well...for a while... but eventually most ACL damaged knees will deteriorate with time. 

Images 1, 3  Google Images

Sunday, June 12, 2011

Ironman Kindness, This Could Be You

Racing season is in full swing and my "local qualifier" Eagleman 70.3 run by the affable Bob Vigorito is today.  Bob's had a tough year beginning with a bike crash in Kona leaving him with a collapsed lung, nine broken ribs and a number of other injuries.   He's had surgery on both shoulders since and may facing a spine operation.  But he never stops smiling, helping athletes and contributing to the sport.  Thanks, Bob.  Good luck with the race today.

With that in mind, I wanted to re-issue these two interactions to remind all athletes to thank both the race director and the volunteers.  Without them you'd be at home waiting for the NBA to come on TV.  And as the bumper sticker says, Triathlon takes two balls.

John Post, MD

Two Ironman Stories, 10/9/2010 Kailua-Kona, Hawaii

Sometimes, in surprising ways, the human spirit of kindness saves the day. A triathlete I know, despite his best efforts, is tad forgetful at times. I worked the men’s changing tent in Hawaii last year when this gent came in flying after a pretty good swim. As is custom, he dumped his bike transition bag on the floor, quickly changed in to his biking gear, and was out the door. In a matter of seconds he was back having forgotten an item. He eyed me, and asked if I could find his bag and retrieve it. Well, if you’ve ever served in this position, you know that there are 50 men at any one time in the tent, all moving as quickly as they can in many different directions, and the stress level is right high. In short, it’s controlled mayhem with a great deal of activity in a very small space. Also, when an athlete is dressed and out the door the bags are thrown into one huge pile to be sorted later.
But, he hadn’t been gone long so I gave locating it a try. After searching through about 50 bags, we realized the futility of our efforts and he abandoned the search sprinting toward his bike (which went fine by the way.)
Fast forward to 2010, same situation – different volunteer – and our buddy is out the door…and back in a flash having forgotten his sunglasses. These are pretty important given the wind and heat of the Queen Ka’ahumanu Highway and the near complete absence of shade. Again the volunteer made a noble, but unsuccessful search for the bag containing the sunglasses. Without hesitating he said, ,“Here, take mine!” At first this gent protested, but after a second offer , an order actually of, “Take mine”, the athlete did and had a quite successful ride. At T2, he looked for that volunteer but there’d been a shift change. The sunglasses were left with thanks and instructions for return to the volunteer.
This helping gesture, non-competitor supporting competitor was done in the truest spirit of triathlon. I think that both of these folks benefited from this spontaneous and selfless act.

One of my roles on Saturday was being stationed at the entrance to the men’s changing tent. At the debriefing last year, it was noted by many that the pros exit the swim like a house on fire and when they tried to change direction to enter the tent, they lost footing ending up on the ground. My goal was to eliminate this for 2010. It worked. By simply getting eye contact with the athlete and actively directing him to turn, nobody “went to ground.” In fact it worked so well I was encouraged to keep my position and direct the age groupers, women to the women’s tent, men to the mens. And, it was almost completely successful. Almost! When you consider 1800 swimmers passing by you in a six foot wide space they almost suck you along. I was able to prevent 9 women from mistakenly entering with the men…but not the tenth. This somewhat smaller woman was directly behind a large body athlete and it was only out of the corner of my eye that I saw her slip in. But, because of the sheer numbers of bodies, I was blocked for a moment from following her into the tent. By the time I was able to thread my way in, she was already dumping her bag and ripping off her swim suit – almost. Interestingly, she was so focused on the job at hand, she didn’t notice that she was the only woman in a tent with forty men in various stages of undress! In one quick movement I got her arm and her bag. Exit stage left and back to my post. One can only imagine the reaction in the tent if I'd missed. As they say on TV, priceless!

Monday, June 6, 2011

ACL Tears - Part One

I’ve been waiting for my dreams to turn into something I could believe in,
And looking for that magic rainbow on the horizon.
David Cook, Time of My Life

We are in a different paradigm in sports than we were only 25 - 30 years ago.  As a society, we've  seen a notable increase in sports participation, young and old, male and female. Think about the emphasis on women's sports on the collegiate level.  Or perhaps more importantly, the way we view kids athletics has undergone a significant shift.  Think about how much free play kids used to have, recess, gym class all 4 years of HS, where now the emphasis seems so biased toward organized sports.  They are pushing harder (being pushed?) in basketball, football and even triathlon.  With this change has come an increase in injuries seen.  If you look at an older pediatric Sports Medicine text, you'll find little to nothing about this injury where today, look at a girls senior soccer team and ask how many have had ACL tears?  Lots would sometimes be the answer.

Children and adolescents are not just "little adults." The problems that appear in the face of ligament deficiency are considerably different than those seen in mature adulthood.

First a little anatomy

The knee is not a hinge joint like the elbow. Rather, it's known as a ginglymus joint.  This is one that also rolls, slides and pivots.  And since participants in our sport range from Tri Kids to those over 80, we need to differentiate the medical and injury needs between them.  There are four bones which make up the knee including the femur, tibia, patella and fibula.  The four major ligaments include the medial and lateral collateral ligaments supporting the inner and outer sides of the joint, and the anterior and posterior cruciates (ACL and PCL) more centrally located.  In the anatomic specimen we see the glistening articular cartilage lining the femur and the easily recognized anterior cruciate ligament partially obscuring the PCL.
This ligament originates on the femur laterally and inserts centrally on the tibia. If you look closely you can see that the ACL is composed of number of individual fibers which seem to twist over it's course. It serves both a stabilization function as well as proprioception (position in space.)  This is accomplished by resisting anterior translation under the tibia, acting as a center of rotation as one is straightening the leg and aiding in prevention of hyper extension.  It's among the most important structures in the joint and it's not hard to understand why injuries to it are labeled the "widow maker" by some.


 Just because you’re not on an NFL team don’t assume you’re immune to tearing your ACL.  While it’s true that one of the more common causes of injuries to this ligament is force, motor vehicle accident, football or basketball, etc. about half of the ones that come into my office simply suffer a twisting injury,  be it on wet grass, slipping down a hill, jumping out of the back of the truck, what have you.  Tiger Woods might be a good example of this.  I can’t tell you how many folks say, “I did it all by myself.

 You might ask if some are more likely than others and the answer would be yes.  As noted above, with Title Nine funds and a greater equality in sports participation and funding, the number of females rupturing their ACL’s has increased at a much more rapid pace than males.  This has lead to researchers carefully comparing the anatomy of the male and female knee bone structure.  They've learned that frequently the space available for the ACL is tighter in women than men.  This has been postulated as one of the sources of tears.  Females also have knees that hyper extend more commonly  and this is seen in groups who rupture. 

 There’s a reportable number of athletes who’ve torn both ACL’s and whether this is activity specific or personal anatomy specific has yet to be determined.  I’ve repaired ACL tears in sisters, brothers and one husband and wife pair.  Approximately one in1,000 – 10,000 of us is both without ACL’s.

 So, the most common presentation is a person quite normal up until the injury when they report an audible “pop.”  They will frequently complain of the immediate onset of instability, rapid accumulation of swelling and a slight warmth to the joint.  Patients like my son Ben who’ve dislocated their kneecap, or someone with a big meniscus tear, fracture etc. may have similar complaints.

I’m running out of space so next time we’ll cover what’s found on physical examination, why treatment is important, and those treatment options.