Sunday, August 28, 2011

Joint Replacement in Triathletes

"And I'll taste every moment and live it out loud,
I know this is the time, this is the time to be more than a
name, or face in the crowd, I know this is the time,
this is the time of my life."     David Cook, American Idol

Been told you need to have a joint replacement?

Well, this will make a major change in your choices of sports.  I talked with one of the companies that manufactures joint replacement products to see if there'd been any major changes in the recommendations for those who've undergone knee or hip replacement.  I'm sad to report that there have not.  Joint replacement is the end resort when a patient has unrelenting pain accompanying arthritis of a joint.  The orthopedic community has improved the current artificial joints to where we now feel that they should last approximately 20 years depending on the age of the patient, weight, activity choices, etc.  The operation is performed as an in-patient, under anesthesia,  and a hospital stay of 2-3 days is common.  Frequently you are encouraged to put all your weight on the operated limb from day 1. Potential complications include bleeding, blood clots, infection, surgical failure to name just a few.

Once fully healed, you will be encouraged to swim, bike, dance, stretch, etc. You may note that participation in triathlons is not found on the list and for good reason.  One's goal is to get the joint to last as long as possible, potentially for the rest of your life. Re-operating on an artificial hip or knee is significantly harder than the initial procedure, the results less certain and the possibility of complication higher. That said, one recent study found that 80% of hip replacements in patients under 65 were still working well at 15 years while 94% of those over 65 had the same success.  It's felt that risk factors that shorten the longevity of the prosthesis include weight, age as just noted with being under 65 a risk factor, choice of activities (even though some may not hurt they may over stress the new joint), avoiding complications like fracture around the prosthesis, infection, dislocation, etc.

When I earned my MBA before med school, in Marketing class we learned about early adopters, a sub group of folks who don't mind a little increased risk or expense if they can have the latest and greatest products around.  Sound like anyone you know?  Like most of the triathlon community?  You bet. But, in this situation, it may be best to work carefully with your surgeon as the newest product that may be well intentioned, designed to last a lifetime in all, may not.  One of these is called hip "resurfacing" in which less bone is removed and a cap placed over the head of the femur.  It's specifically marketed to the younger patient.  Floyd Landis had one in 2006.

Although we as physicians think we have the answers to longevity through research, one of the manufacturers is encouraging real world answers to patients who have one of their joints implanted.  in other words, regardless what what they were advised to do, what have they really done and has it affected the joint wear?  One example of this was a woman I saw on Slowtwitch, several years out from a hip replacement, who did iron distance racing.  Or a gent I met in my first Ironman in 1982 with a total knee replacement who'd suffered a gunshot wound to the knee as a serviceman in Vietnam.  These folks and others like them will continue to contribute to joint replacement research, hopefully with success galore. 

Images 2, 3 Google Images

Sunday, August 21, 2011

ACL Tears, Should I Fix Mine?

"I always wanted to be somebody, but now I realize I should have been more specific."               Lilly Tomlin

ACL Tears 2011

My last blog from a couple days ago discussed "what it you need surgery?"  This is the next step in that discussion.

    It wasn't that long ago that the triathlete who tore his/her Anterior Cruciate Ligament had suffered a career ending injury.  But, over the last 30 years, particularly the last 10, we as an Orthopedic Community have improved both our understand of the structure, location and function of the normal ACL as well as it's reconstruction.

As seen in the images above, the normal ACL spans the knee joint between the femur and the tibia.  It is a stout structure which limits the forward travel of the tibia under the femur as well as playing a role in rotational stability.  While seldom injured when a blow occurs to the limb, they will rupture when a twisting force, like falling off a bike or slipping on a wet pool deck, is applied across the joint. When this happens, the knee fills with blood and it's normal stability pattern is frequently lost.  A torn ligament is not repairable.

 Now What?  An ACL reconstruction is a pretty big operation with a sizable rehab commitment that nor everyone can or wants to follow. In the not too distant past, it was reserved for high performance athletes but the above noted improvements have lent this operation to older (and younger) patients.  The physicians in the Arthroscopy Association of North America when recently polled "recommend reconstruction in 98% of their patients."  The old adage of not having this operation between "3 days to 3 weeks" post injury seems to hold true in many.

Like many knee operations done today, this one is done pretty much arthroscopically but that's where the similarity ends.  To reconstruct a torn ligament one needs something to put in it's place.  This can be something from you or possibly another source such as the the local tissue bank.  The two most common options from your own knee include a small portion of your hamstring tendons or the middle third of your patella tendon.  When using a tissue bank and donor tissue, the choices are virtually limitless.  Examples would include hamstring or patella tendon, Achilles tendon etc.  Which of these is ultimately utilized is up to the patient and surgeon, and at one time or another I've used all 5 sources.

Once that decision is made, and the pre-op amenities taken care of, you'll find yourself at the surgicenter discussing choices of anesthesia with the anesthesiologist.  Listen carefully and choose which method seems best for you.  It will not make a difference to the surgeon. Depending on what needs to be done to your knee the procedure will take 1.5 to about 2.5 hours and you'll wake up in the recovery room, frequently with a brace on your leg and a device circulating ice cold water around your knee to help with pain control. Once you're fully awake, the pain is under control and you feel like it, they'll let you go ACL and all! You'll undergo pretty detailed physical therapy in the coming months and likely miss the rest of the racing season but you've just made an investment in your future and can kick butt next season.

Image #2 Google Images, 3# Bryce Groark

Wednesday, August 17, 2011

Surgery, What If I Need It? Plus, Winning Transitions

He who will not risk will not win.”

                        John Paul Jones

"You’re going to need an operation." 

Now what?

    “And then he walked out of the room.”  If you’ve never had surgery, being told that the next  step in your care involves a trip to the operating room can be a tad upsetting.  What’s going to happen to me? How long will it take to get over it?  Can I pay for it?  Are you sure there isn’t another way to get better?

 These and a 1000 other questions run through the mind of the new patient as he/she’s been told, for example, that their shoulder will continue to dislocate unless something is done surgically to prevent it.  Although it seems difficult, maintaining control is important and having some idea of what questions you need the answers to helps.  In this setting, our shoulder dislocator will probably have a discussion with the surgeon about the procedure, basics of the reconstruction including risks, location of the incision, time in hospital if any, post op therapy and finally return to sport.

 There will also be a discussion with the nurse/assistant covering the nitty gritty details like agreeing on a date for the operation, where and time, diet, what to wear, pre-op blood or lab work if needed, and all the little details that are so important to the patient.  In our office this often includes a video about the surgicenter, parking, and an example of someone else going through the same basic surgery to try to put them at ease.  Also at this stage is the first of several permits that you’ll be asked to sign, the permit for surgery.  In our exceptionally litigious society this is the first document that you’ll see explaining the basic nature of what will happen to you and the basic risks.  You’re giving the surgeon permission to do the operation understanding that positive results, while implied and hoped for, are not guaranteed.  If you have any doubts, want a second or even third opinion, now’s the time to do so!  You’re the one having the operation and need to feel not only is it right for you but that this surgeon and medical team are also right for you.  It doesn’t bother the surgeon at all if you say you need to delay the procedure, ask around, and in fact some docs actually encourage it.  There are some operations that get better results early, (when not delayed) however.

You’ll also probably talk with the insurance office.  On the day of surgery you’ll arrive at the hospital/surgicenter an hour or two early, change into one of those funny gowns that opens in the back, meet the anesthesiologist  - another permit – and discuss the options for anesthesia, picking what’s right for you.  There may be an IV involved also.  And when your turn comes, off you go into a whole new world.

 Good luck!

“I always win the transitions!” says a patient of mine. And he does.  I think he feels that more important than the race results.

Here’s how.  He makes things very simple. 1) only bring into the transition area what you absolutely need, 2) Practice, practice, it’s all in the set up, and 3) Keep it simple.

 The day before the race, know the course cold.  It’s so easy to memorize. On race morning when you rack your bike and drop your stuff do a nice slow walk through from your bike to the mount line and from the swim exit to your bike.  Do it a couple times (not talking to your friends but to memorize it.)  it will also help you relax some.

 Anyone can have a lightning quick wetsuit exit.  If you ever have the pleasure of volunteering at the transition area of a sprint tri, watching the comedies of wetsuit removal appears not unlike Harry Houdini and his 1920 straight jacket act or the wrestling of an invisible opponent.  First, Training Bible Coach Jim Vance will tell you to cut off the bottom hands breadth of the legs off the suit. "I guarantee you it will make no difference in your swim" he says, you’ll just get your feet out faster. And PAM sprayed around the ankles will make this remarkably easier. (Just make sure you use regular PAM as the flavored types seem to attract hornets, as one triathlete found out the hard way.)  As you exit the water, you’ve unzipped the suit – while moving, you’re always moving – and a shrug or two aids in getting the top down to your waist giving you the appearance of the so-called “headless monkey.” At your bike, a quick pull gets the suit to your knees and Coach Eric Sorenson of the Annapolis Striders would tell you to simply step on the suit and pull your foot out .  All this in under 10 seconds. Remember that pre-race practice stuff?  Your race number is on a belt under your wetsuit so it’s helmet, sunglasses and go!  Forget that toweling off and foot bath stuff – unless it’s part of a pedicure.  Really, you won’t blister in a sprint race.

 That your bike shoes are already clicked in and fixed to the pedals with rubber bands, left pedal forward assuming you mount from the left, is a given.  This has been shown time and again to be the quickest.  If, during your home transition practice before the race, you ride barefoot with your feet atop the shoes for 5 or 10 minutes you’ll see how easy it is giving you one more learned skill that may be important one day.  In the race, you’ll have a quick mount well away from the start line and other riders.  The mount line has the highest potential for collisions that might ruin your day.  When you return to T2, slip on those lace locked running shoes, grab your hat and you’re off.  Some cannot do this standing up and will duct tape a towel to the outside bottom of a plastic milk crate, place it right next to one’s front wheel, and use it as a quick seat to apply running shoes.  It also makes for a handy way to transport your gear in/out of the transition area.

 Compare your transition times to those in your age group, and to your performance last year and YOU WILL BE THE QUICKEST!!

 And remember, SUPPORT THE SPONSORS THAT SUPPORT YOUR RACE.   It wouldn’t be bad taste to also wear their logo.

Monday, August 15, 2011

Not Yet Ready For The Glue Factory

"When prescribing one of the drugs I take, my doctor warned me of a common side effect: exaggerated, intensely vivid dreams. To be honest, I've never really noticed the difference. I've always dreamt big."         
                                                                               Michael J. Fox

T-shirt in Hawaii

This is the time of year when a select few of the triathlon dreamers are paid off.  It's almost KONA TIME.   I haven't missed one in years and my biggest reward is helping the first timers by working many hours on the pier to make sure that it's perfect for those racing.  I just love it.

But many of us have dreamed for years only to have those wishes squelched by reality.  Too old, too slow, too everything.  And in those criticisms chimes in injury, pain, aging, etc. causing many among us to bring their racing career to an end.  Or, they at least modify it trading distance events for sprints and what not. And I think that's just fine.  Normal. The way things should be and not something to either bring on regret or be embarrassed about.

Post race: Note red slash through the number - a penalty, likely drafting.

When is it time to call off the dogs?

Jim is a 42 year old triathlete who e-mailed me recently after his third knee operation.  A high school football player, he'd torn one of his knee ligaments, undergone successful reconstruction, and played his senior year.  But it cost him nearly a year of no sports.  Fifteen years later, without much trauma, he'd needed arthroscopy to remedy recurrent swelling.  A "touch or arthritis was found," he says. He gravitated away from pure running to triathlon to "give my knee a break" and really took to the sport.

Well, he got a decade out of the knee as long as he overloaded swim and bike training keeping running to an absolute minimum.  Now, even that doesn't work. He's had another "clean up" operation and the arthritis is worse.  he's only 42!  So, what advice do you give to Jim?  Have a knee replacement and quit yer bitchin'?  Not hardly. Or, the tri forum answer for all questions from pain to finance to marital discord, your seat's too high?  (Just kidding.)

Seriously, we will all face the day when we are forced to ask ourselves, "Do I need to back away from triathlon?  It's usually not the best of days but does require honesty.  And we as triathletes are not good at that when it comes to self-knowledge. It's a process and will probably occur spontaneously over the course of several years.

One athlete I know had his "moment" at mile 20 on the marathon in Kona about 6 years ago. He was walking.  He'd been walking. His feet hurt, his back hurt, he was dead tired, and just like the Truman Show where everyone is watching you, he felt everyone along the course was watching him perform at a level far below his best.  "It hit me in the head. I thought 'What am I doing here?' Obviously, iron distance racing is no longer the way I validate myself.  I don't have to do this anymore."

Whether it's injury, family or job needs, expense, the absolute refusal to spend so large a part of every day dedicated to self interest, my training, etc., at one point we'll all make the decision to stop, or at least reduce the triathlon burden in our lives.  And it will be just fine.  Trust me, I've been there done that, and life on this side is just fine.  Heck, I can drink beer whenever I want now.  You?

There's no shade on the Queen "K" highway.

"We're all pretty bizarre, I mean some of us are just a little better at hiding it, that's all."
                                                                                            The Breakfast Club

I'm ending with this quote to remind each of us to keep the role of triathlon in perspective.  For some it's a life long pursuit at a high level, best of the best, but for most this isn't true. Take from triathlon what it will give you, give back what you can,and when it's time, cast off for a new adventure.  Life is what you make it.

And always say thank you to the volunteers!

Saturday, August 13, 2011

Mid/End of Season Injury Self Eval

Despite recent shoulder surgery, this triathlete is still volunteering.

"You want to be famous? Learn how to take blood out of car upholstery?
                                                                John Travolta, Hairspray

This is the time of year for goal review, for updating planning, and determining if the path we're walking (our 2011 training plan) and see if they have lead to success, limping...or both!

Consider that, according to a piece in the British Journal of Sports Medicine a couple years ago the ten most common overuse injuries that are seen in the running population are:

1. Patellofemoral pain (21%)
2. ITB Friction Syndrome (11%)
3. Plantar Faciitis (10%)
4 Meniscal Injuries (6%)
5. Shin Splints (6%)
6. Patellar Tendinitis (6%)
7. Achilles Tendiniitis (6%)
8. Gluteus Medius Injuries (4%)
9. Tibia Stress Fractures (4%)
10.Spine Injuries (3%)

Note that the key word here is OVERUSE. Since this is only early August, this is a golden opportunity to potentially revise one's schedule for the training and the remainder of the racing season. Adam Zucco, Age Group winner at IM California 70.3 both of the last two years, and Training Bible Coach would have his coached athletes list their planned races for the upcoming season and the importance of each. Using the periodization model, he'd set up a 3 weeks on/1 week rest repeating game plan to slowly build, first the mileage, then the intensity (accompanied by a decrease in volume). In other words, he understands the principle of gradually increased load that the body will respond to rather than acute increases in training stress. This will give the racer the highest likelihood of both improving the level of fitness but doing so with the lowest potential for injury. While this is not new thinking, getting it right can be a chore.

As you revise your plan, remember that frequently runners will come in to the clinic and have a single work out that pushed them over the brink. Oftentimes this was something foolish like racing against a friend, pushing thru pain when they knew they should stop and walk, beer miles,etc., that will cost them a part of the season, and, as they used to say in the U.S. Army commercials, the opportunity to "Be All You Can Be." The time to start thinking was yesterday.

Hey lady, did you know there's a bird.... 

Thursday, August 4, 2011

Foot Surgery (Cosmetic Foot Surgery), Do You Really Need it?

" I have given a name to my pain.  It is Batman."
                                                                   Jack Nicholson, The Joker, Batman

“If more people ran, fewer would be dying of degenerative heart disease, sudden cardiac arrest, hypertension, blocked arteries, diabetes and most other deadly ailments of the western world.”

                                                                                           Born to Run

 While there may be some minor medical inaccuracies, the sentiment rings true.

Triathlon Lifestyle 

As triathletes, our lifestyle may seem a bit odd to some outside the sport.  When noticed, some athletes use it as an opportunity for self-promotion, “Ain’t I grand…..why, yes, those are compression hose under my business suit…how did you ever notice?”  But for most of us, the life choices are about fitting our training in around the schedules of others without being too much of a bother.  And, if they stick out a little, having made a commitment to health, so be it.  Michael J. Fox may have said it best noting, “What other people think of me is not my concern.”  I know one triathlete who makes a habit of doing for others, particularly at work, and the fact that she rides her bike to work…occasionally having stopped by the pool for a couple thousand yards first, makes her all the more valued as an employee who contributes to the bottom line.

“Cosmetic” Foot surgery

For those of you who might be concerned about the appearance of your feet, some would be motivated to seek out a professional who could perform an operation to perhaps “normalize” them.  Others might see an inability to wear a particular type of shoe be it for athletics or fashion and wonder if surgery might be the answer.

There may have been a time when some would tout the benefits of a “30 minute procedure” in someone to prevent the development of a bunion, straighten a painless toe that’s a little crooked or even augment the fat pad found on the sole of the foot to accommodate high fashion foot wear, etc.  But those days are gone.  Both the American Orthopedic Foot and Ankle Society and the American Podiatric Medical Association have put out a position statement to the effect that,

"…foot surgery not be performed simply to improve the appearance of the foot.  Surgery should never be performed in the absence of pain, functional limitation or reduced quality of life.”

v  ….yet there are many proponents in the field who argue that the procedures are safe and justified.  But, consider the risk.  In addition to the usual bleeding, nerve damage, surgical failure, etc. one faces the potential of recurrent deformity or development of life long big toe arthritis.  In fact, for many of these complications a successful revision procedure is not available!  In short,  it may not allow them to wear more attractive shoes and may put them at risk for a lifetime of chronic foot pain.

So the take home lesson here is that while foot surgery, or any kind for surgery for that matter, may be occasionally indicated, the educated patient who’s aware of alternatives and the potential for problems is likely the one who’ll get the best result.


Image 2, Google Images