Sunday, July 31, 2011

Bursitis Hip, Knee and Elbow

" can't always get what you want.
But if you try sometimes,
you might find, you get what you need."

                                                                       Rolling Stones

I've heard that the following was a serious question; "Was Paul McCartney in a band before Wings?" 

I 'm afraid, as it's it's been pointed out many times, that those of us who do not understand the past are doomed to repeat it.  With respect to injury, triathletes continually repeat the errors/oversights of those who've raced before us.  With the same poor results and lost time training I might add.

Now that we're smack dab in the middle of the summer, and more and more of us are at the peak of our training year, there will likely be a commensurate increase in sore, aching limbs.  It will be pretty tempting to ignore these "minor aches and pains" or treat them with a little I'm an Ironman liniment, but a wiser choice might be to pause and seek out the cause of this distress.  Is this pain secondary to bursitis or an inflammation of the fluid filled sacs (bursal sacs) that surround or cushion our joints?

Bursitis is a condition that causes these sacs to become irritated or infected heralding pain associated with motion.  If this is diagnosed as infection, prompt intervention by the medical team is important to keep the process localized and (hopefully) minimize it's severity.  As noted in this blog two weeks ago, the patient presenting with joint pain, say an elbow for example, has the potential for this to be arthritic, tendinitis, stress fracture, etc. and the care giver must differentiate between these entities.  If the working diagnosis is bursitis, culling out the infected from non-infected is the next step.  We've previously noted that bursitis of the heel is predominantly an overuse type issue as is the hip.  When considering the knee and elbow, so-called pre-patella bursitis and olecranon bursitis, we generally think of a chronic or low level of trauma keeping the potential for infection on the table.

Symptoms of bursitis might include pain in the vicinity of the joint, an actual swelling of merely a sense of fullness, warmth, and/or redness.  In the hip this is called trochanteric bursitis and is usually found over the bump on the outside of the hip frequently radiating to the thigh.  It's worsened by laying on that side, stairs, or upon standing from the seated position.  The elbow will demonstrate a fluid collection over "the point of the elbow," frequently involving infection.

    In the knee, this has picked up the term "housemaids knee" and occurs after prolonged kneeling, previous injections, kidney disease, etc.  One can actually see the swelling as a pocket or pouch over the front of the knee.  Infection is part of the suspected diagnosis.

Treatment of bursitis usually does not involve surgery and can include compressive dressings and ice, changing ones activity to avoid/lessen the offending stimulus, aspiration and culture to determine presence/absence of infection - primarily in the knee and elbow.  Those determined free of infection may occasionally be candidates for a corticosteroid injection.  That said, if steroids are administered to one that's infected matters can be made much worse!  NSAIDS and antibiotics will commonly be part of the plan.

In short, as in many problems presented in this blog, early diagnosis and treatment with careful follow up give the highest probability for success and return to the age group wars!

Images 2 and 3, Google images.

Thursday, July 21, 2011

Fluid Management, Work Out Guilt

Feel guilty when you miss a work out? Does a situation like this sound familiar? Your airline cancels your flight home and you're forced to get a rent-a-car for your final leg.  You finally walk in the front door at 4 am, beat.  Now what? Should I can my morning work out?

This decision, or one like it, is one we constantly face through out the season.  Being mentally prepared before it occurs will make it less of a physical (or psychological) negative.  As noted in these pages before, the sport of triathlon attracts those who thrive on consistency. An addictive behavior of sorts.  And, when that behavior - the work out - is accomplished early in the day, we're relaxed, sharing, fairly normal individuals.  But, upset that apple cart with travel, a vacation, an unexpected meeting, etc. and the "addict who misses his/her 'fix' " surfaces.  Although it's obvious, the season doesn't hinge on one work out, one day, or even one week. If this can burned into one's brain early in a tri career, your family and workmates will be better for it...and so will you.

I thought he'd be done by now.

Remember that we're also part of a family team and their thoughts, needs and priorities need to be part of the equation.

A comment on fluid management appropriate for July.  "Plus the air is so dry that by the time you feel thirsty, you could be as good as dead; sweat is sucked so quickly from your body, you can be dangerously dehydrated before it even registers in your throat. Try to conserve water, and you could be a dead man walking." Born to Run, Chris McDougall    Although he's describing running in Mexico's heat, the message should be clear.  A local high school runner died a few years ago in the heat - plan your runs, don't neglect re hydration, and if you can avoid the heat of the day, all the better.

It's said that some years the road surface temps exceed 120 degrees.  As you might expect, there are differing perspectives on the best way to maintain fluid balance and each of us needs to understand what works best for us as individuals.  The best strategy for your training partner might or might not work for you. Some advocate directing fluid intake by thirst, some by schedule, and others a plan - like your nutrition plan - that's been worked out by you during pre-race training.

I happen to be in the latter camp.  I believe that it's just "cake" to keep track of your fluid intake, type and volume, during your long rides/runs...and then importantly the next several hours, to determine your specific race needs.  Keeping track of the temperature and relating this to the temperature on race day is also helpful.  This is not to say that you won't get dehydrated during the actual race.  You will.  But there's a point beyond which our performance diminishes as you well know and if we can skirt that level, we win.  In short, you plan everything else before a race, in my opinion, fluids get planned as well.  But only after practice, practice in the pre-race setting. (Personal Note: although my iron distance career is complete, one of the best days of my year every year is working as a volunteer athlete escort in Kona.  After bike inspection, the athletes need to rack their bikes and transition bags and understand the intricacies of transition entry and exit.  I try to get only first timers, walk them through this whole process, and visualize their whole experience on the pier.  Where/how do you come out of the water here?  Exactly what route do you take? Have you reviewed flat tire repair recently?  How do you plan to handle the heat and fluid needs?  And 100 other questions so that when they walk off the pier, unknowns have been changed to knowns.  There's enough to worry about on race day.  If I can make their day a little smoother - good deal.)

2 mile mark on Hawaii bike course. (Not everything is cake, though.)

Saturday, July 9, 2011

Bursitis, You Probably Don't Need Surgery; Is Stretching of Value?

At your local bike shop soon, avoid the Christmas rush!
Mt. Whitney Calls - I'll be away for the next ten days as my two sons as I head to California's beautiful Sequoia National Park to hike the High Sierra and John Muir Trails and then summit Mt. Whitney.  At 14,505 feet it stands as the tallest peak in the lower 48 states.  So rather than swim, bike, run,'ll be hike, hike, hike!

A recent triathlete's letter asked for help with his "heel bursitis" only I wasn't sure that was a correct diagnosis.  This is an exceptionally common scenario for so many who get their medical care from Internet chat rooms.  Heel pain for example is, to some, plantar faciitis, because it's the only diagnosis they know.  In fact the heel can be a very busy place and just a couple of the diagnoses that spring to mind could include:

1)  Posterior tibial tendon problems
2)  Tendonitis of either the peroneus longus or brevis
3)  Achilles tendon rupture, partial tear or tendinitis
4)  Stress fracture of the calcaneus (heel bone)
5)  Fat pad atrophy
6)  Infection or tumor
7)  Tarsal tunnel syndrome
8)  Plantar faciitis
9)  And, oh yeah, bursitis.  But is it the retroachilles bursa, retrocalcaneal bursa, etc.

My point here is that so often the questioner has only a vague suggestion of accuracy in his/her diagnosis and without a specific explanation of the source of the problem, how are they ever going to improve?  Yours odds are improved by a thorough history and physical, and occasionally some medical tests may be needed to help the medical team identify bursitis and determine whether or not infection is involved.

So, today we'll cover heel bursitis and save bursitis of the knee, hip and elbow for another time.

Heel bursitis, or in this case more accurately retrocalcaneal bursitis occurs between the back of the heel bone and the front of the Achilles tendon.  Much less frequently we find problems with the subcutaneous calcaneal bursa seen above or the retroachilles bursa (didn't expect it to be so confusing did you?) but today we'll stick with the former.  The bursa acts to decrease friction in the area where two structures move in different directions.  Bursitis then is inflammation of the bursa, diminishing it's ability to slide, making it more and more irritated when it's moved.

The cause is multi factorial from repetitive motion or excessive pressure to poorly fitted foot wear that is overly stiff and repeatedly compresses the Achilles insertion.  There can be coexistent Achilles tendinitis and the examiner will check for a Haglund's deformity - a spur on the back of the calcaneus.  Less commonly it will follow trauma such as a bike crash or fall.  In any event, the triathlete will show a red, painful heel which is quite tender when pressure is applied.

Conservative care is the norm with an ice pack and some type of compression dressing including a significant reduction in the offending activity (training) and often the use of a NSAID like ibuprofen.  Many will recommend both a stretching program along with a careful footwear evaluation.  And, even though it's uncommon, infection does occur here and careful follow up is in order.

This was recently posted on, the web site for Orthopedic surgeons and I found it of interest.  I hope you do as well.

Stretching Before a Run Does Not Prevent InjuryHowever, runners who typically stretch should continue, or risk injury
San Diego, CA
Stretching before a run neither prevents nor causes injury, according to a study presented today at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).
More than 70 million people worldwide run recreationally or competitively, and recently there has been controversy regarding whether runners should stretch before running, or not at all. This study included 2,729 runners who run 10 or more miles per week. Of these runners, 1,366 were randomized to a stretch group, and 1,363 were randomized to a non-stretch group before running. Runners in the stretch group stretched their quadriceps, hamstrings, and gastrocnemius/soleus muscle groups. The entire routine took 3 to 5 minutes and was performed immediately before running.
The study found that stretching before running neither prevents nor causes injury. In fact, the most significant risk factors for injury included the following:

  • history of chronic injury or injury in the past four months;

  • higher body mass index (BMI); and
  • switching pre-run stretching routines (runners who normally stretch stopping and those who did stretch starting to stretch before running).

“But, the more mileage run or the heavier and older the runner was, the more likely he or she was likely to get injured,”
“As a runner myself, I thought stretching before a run would help to prevent injury,” said Daniel Pereles, MD, study author and orthopaedic surgeon from Montgomery Orthopedics outside Washington, DC. “However, we found that the risk for injury was the same for men and women, whether or not they were high or low mileage runners, and across all age groups. But, the more mileage run or the heavier and older the runner was, the more likely he or she was likely to get injured, and previous injury within four months predisposed to even further injury,” he added.
Runners who typically stretch as part of their pre
The most common injuries sustained were groin pulls, foot/ankle injuries, and knee injuries. There was no significant difference in injury rates between the runners who stretched and the runners who didn’t for any specific injury location or diagnosis.

Image #2, Google images

Tuesday, July 5, 2011

Arthritis in a "Former Triathlete" - Surgery Upcoming?

A question that comes up all too often is the athlete who wants to compete but due to a medical condition beyond his or her control they find themselves to be "former triathletes."  I've always found this to be a troubling definition as the person is, in one sense, is allowing themselves to be defined by a sport when they have so much else to offer.  I suppose we're all former somethings but just like Julie Andrews says in Sound of Music, "When the Lord closes a door, he opens a window somewhere."  I firmly believe that when confronted with a situation like this, opportunity is knocking somewhere else in your life and that before too long, you'll open the door where this knocking occurs.

The following is a letter I received today that may reflect this approach to life:

I'm a 51 yo former triathlete who can no longer run due to an arthritic knee that is "bone on bone." I had my last of 3 surgeries in May 2011 and have not been able to run more than 3 miles without increase in pain. This is after a series of 5 sinvisc (sp) shots. They lasted 3 months , but after that back to the pain. I currently swim 15k a week and ride 6 hours w/o too much discomfort save for a hilly , hard ride, then it starts to hurt. The next step is partial or full knee replacement. Can you tell me if there is a chance of running after such a surgery and is there a criteria/series of questions to help a patient decide to have knee replacement? Thank you for your blog, Chris

This is a slight modification of my response.

Chris - this is a big problem that faces many triathletes. As you scan the number of entrants in each age group at your local triathlon, as we age the number of folks in each older group is less than the one preceding. And you know that there are a bunch of former triathletes (like you) who'd like nothing better than to be at the starting line but can't because of arthritis such is present in your knee or some other medical issue.

I'm sitting at the airport having just taught an Orthopedic course to a couple hundred primary care docs this morning and this is what we discussed. Arthritis of the knee comes in many flavors. Some have worn through the cartilage over a wide area while others have a smaller lesion surrounded by normal tissue. It sounds like you're in the former category and replacement, if it's just killing you, may be a surgical option. But, at 51, if you can modify your activities such that you can put off any kind of surgery as long as possible, that might be the best path. If you have such pain that the above is not an option, the partial replacement, Unicondylar Knee Arthroplasty, is a good option if your disease is predominantly over only half of the knee. It's a smaller operation than a replacement, no ligaments are cut and motion down the road tends to be better. I like it.

As far as running after either procedure, I don't think you'd find a manufacturer that would support it. In the global picture, you want whatever is done to last the rest of your life, if possible, and if you have a lot of life left, you'd want this to survive as long as possible before you undergo surgery again. Golf, doubles tennis, light aerobics, hiking, etc. are all on the recommended list.  Running is not.  In short, if my brother had a UKA, I would encourage him to be a biker-swimmer-hiker, etc. but to wear his running shoes when he cuts the grass. I suspect that your best advice will come from your surgeon who knows your knee better than any of us. And, while you may on one hand be a former triathlete, I'll bet you're a present something else that will ultimately be even better.  It's only a sport and you're so much more than a sport.  We're pulling for you.  Good luck!

From Michael J. Fox - "It may seem hard to believe, but it's catastrophe that offers the most promise for an even richer life."

Image #3, Google images

Saturday, July 2, 2011

Surgery, What if You Need It?

"Standing on a corner in Winslow, Arizona, such a fine sight to see.  It's a girl my Lord in a flat bed Ford slowing down to take a look at me."
                                                   The Eagles

The Triathlete Mindset?

The Girls getting ready for Dad's Ironman finish.

Appreciate Summer:  You're out the door at 5:15 am for that morning work out, no gloves, no tights, no coat, and you hardly need a flashlight if you need one at all.  The same is true for the sunlight lasting well into the evening.  It's pretty easy to get caught up in this and stay out past the time that you have lights and reflectors for.  Be prepared. And, oh yeah, tell somebody your approximate intended route....just in'll be glad you did.

ACL tidbit: A follow up comment on whether or not, if you tore your ACL, would your orthopedist recommend reconstruction. In a recent survey of the membership of the Arthroscopy Association of North America, when considering the young, competitive athlete, 98% of these docs recommend the procedure.  76% will generally perform a reconstruction on the 35 year old recreational athlete but when that athlete gets to reach 50 and has been out of triathlon for a while but still runs three times a week, the number drops to 35% recommending acute surgery.  Stay tuned.

Surgery, What if You Need It?
     Not long ago I received a letter from a triathlete facing the potential of surgery and she wanted to do "Anything to avoid it."  I explained to her that in some cases, the shortest distance between you and competing at full strength may be a surgical procedure and that so-called conservative treatment will only delay the inevitable.

In the 1982 publication, The Complete Triathlon, the author notes "Too Many Surgeons - Too Much Surgery!"  It's a charming text complete with blank pages in the back for "Triathlete Autographs."  So, the rub against surgery is not new.  Unfortunately, the author advocates things like Chelation Therapy for coronary artery disease (atherosclerosis), a "non-standard therapy" in which the patient is administered an agent frequent used in heavy metal poisoning, mercury, zinc, lead. etc. but "The American Heart Association states that there is 'no scientific evidence to demonstrate any benefit from this form of therapy.'"  So, you're back to the potential for surgery.

Surgery has progressed enormously in the past few decades.  Heck, we don't use near the number of leaches that we used to.  For example, if you're told you have torn cartilage in you knee and athroscopy has been recommended, the surgeon is suggesting placing a 4mm fiber optic scope in the knee to first confirm the diagnosis, and then with other equally small incisions, put tiny instruments into the joint to fix what's found.  The inside of the joint is usually photographed and, in my practice at least, we give the photos to the patient.  Good for Christmas cards and the like. Plus it makes the patient feel that they have some sense of control.

These procedures are frequently not performed under general anesthesia and the patient can watch the operation on the same TV the surgeon uses in real time. If you're undergoing a more complex procedure such as ACL reconstruction, rotator cuff repair of the shoulder, this may not be true. The scope can successfully treat problems in the knee, shoulder, wrist, hip, ankle, and elbow. Although surgery done this way not requiring a formal incision can have a shorter rehab, the specifics of this would be best left to your medical team.

Each type of surgery has it's own risks and rewards and each of us would do well to understand both thoroughly before signing on the dotted line.

Image #2, Google Images