Sunday, November 27, 2011

The Female Athlete, Part 1

"Between two evils, I always choose the one I haven't tried before.
                                                Mae West

The objectives of the next couple of blogs will be to discuss the female athlete from the position of the team physician.  What is she/he thinking of when providing care?  Specifically, what are the gender differences between female and male athletes?  And, we'll look at physiologic differences, the female athletic triad and the effects of training on the pregnant athlete. 

No longer should we be discussing the advances women have made in athletic activity and competition.  We now must push the knowledge base for female athletes to the same level as male athletes.  The recent decade has given us much information on treating the female athlete using evidence based medicine but much still needs to be learned.

Athletes:  Male vs. Female
The significant differences between male and female athletes begin just after 10-12 years of age.  The advent of puberty starts these changes.
  • Females reach peak physiological and skeletal maturity before males.
  • Females develop more body fat and less lean body mass than males.
  • Females have less upper body strength even with training but lower extremity strength is much closer in parity with males.
  • Although males have greater red blood cell counts and hemoglobin levels, work capacity studies show minimal differences in oxygen uptake when body size and composition are equally compared between males and females.
  • Women have a wider pelvis and lower extremity alignment different from men that may predispose to injury.
  • Women have shorter limbs relative to body length than men.
  • Women have increased ligamentous laxity compared to men.
Both males and females go through the same physiologic changes with athletic training and can gain significant increases in strength, power and muscular endurance.  This is true even for the aging female athlete where studies show that exercise training can still increase the size and strength of conditioned muscle.
 Women are at greater risk than men for anemia.  Decreased iron stores are found in 40-50% of adolescent female athletes without the presence of overt anemia.  Runners are at greater risk during their training season.  Black female runners have twice the incidence of iron deficiency anemia of white adolescent female runners.  In making the diagnosis of iron deficient anemia, be sure to differentiate this state from sports anemia which results from expanded plasma volume with a normal red blood cell count.  Although only female athletes at high risk for anemia or those with history of anemia should be screened,  some feel that all female athletes should be taking iron supplementation.

Injury Patterns in Female Athletes
The NCAA has been collecting injury data since 1982 for both male and female athletes.  It is hard to compare even on a sport to sport basis as there are different rules and different activities even within some sports like gymnastics and lacrosse.  In soccer and basketball were activities, rules and equipment are similar, females injury rates are 2.6 times greater in soccer and 3.6 times greater in basketball.  In fact soccer followed by spring soccer show the highest rates for female athletes where for males football and lacrosse show the highest injury rates.  Consider the following facts.
  • The ankle is the most commonly injured body part in both males and females.
  • Females sustain 4.9 times the ACL injuries; 2.5 times the collateral ligament injuries; and 1.9 times the meniscal injuries compared to males.
  • The majority of ACL injuries in females are of a noncontact mechanism.
 The higher knee injury rate for females is well established and probably has a multifactorial reason.  The simple diagnosis of anterior knee pain is much more common in females and most easily explained by the physical changes that occur to the pelvis and lower extremities during adolescence.  This may also be part of the reason for the increased rate of ACL tears in females.  Femoral anteversion, external Tibial torsion and foot pronation of the foot combine to create much greater stress on the ACL than in male athletes where the straighter leg can rely on the more dominant hamstrings for support.  The hormonal influences and laxity combined with the above mentioned alignment issues lend to greater injury to the ligaments which in turn increases the risk to meniscal and articular cartilage.
 Studies have shown that plyometric jump training programs for female athletes can increase hamstring strength and approximate male hamstring-to-quadriceps isokinetic testing.  This improves jumping heights and is suggestive of protecting the ACL but final outcomes are still unknown.
 There are also studies showing estrogen receptors within ligamentous structures.  Estrogen inhibits type I procollagen synthesis and proliferation of fibroblasts in vitro but in vivo functions are still unknown.
 Upper extremity injuries also are influenced by the differences between males and females.  Shoulder laxity in swimmers, gymnasts and cheerleaders forms as a vicious cycle of overhead activity combined with physiologic instability leading to impingement and rotator cuff weakness.  Laxity issues also contribute to elbow and wrist injuries particularly in sports with aerial maneuvers where the upper extremity may become a weight bearing limb.

Smiles abound at the Underpants run in Kona

Next time we'll discuss The Female Athlete Triad of:    - disordered eating
                                                                                   - amenorrhea
                                                                                   - osteoporosis

Thanks to Bill Vollmar, MD who first piqued my curiosity when he presented this data in 2008.

Wednesday, November 23, 2011

What's Possible For You In 2012?

"I Felt So Good, Like Anything Was Possible"
Tom Petty and the Heartbreakers, Runnin' Down a Dream

The finish line in Kona about 12 hours after race start.

"ANYTHING IS POSSIBLE" This is one of the catch phrases of Ironman, one you hear frequently in Hawaii. You both hear it as well as see it. Some even live it.

Speaking of  the finish line in Kona, have you read Iron War by Matt Fitzgerald yet?  If not, it's an excellent read and could be that perfect gift for someone for Christmas.

There are so many heart warming stories that come out of this race each year. A good number of the first timers do not meet their expectations and on the morning after the race, honest evaluations of the heat and conditions seep into the conversations for the first time. "Mother Nature always bats last," or some such phrase might be overheard. In spite of this, the athletes share this common bond with the island as they lean back, close their eyes and recall particular portions of their day...both bad and good. And then they smile. That wry smile that comes only with experience.

The above photo is from ALII DRIVE, the finish line, where so many stories evolve. You hear them on race night, "I was just cruising down Alii Drive, man!," or at the Finishers Banquet, "The huge party at midnight at the finish line on Alii Drive was just awesome." Alii Drive, milepost zero, where it all starts and finishes.

By any other name it will always be Alii to the finishers:

NOVEMBER - Dreaming and planning time.

You know how on January 2nd, when you can't get a locker at the health club or gym, and you're used to having light conversations with the regulars, but now there a lots of new folks and the air is almost festive with excitement? Unfortunately, you know from experience that in 60 days it'll be back to the same old crowd.

Triathletes are the same...dreamers all, and at this time of year, they're reviewing recent races, successes and failures, saying, "If I can train just a little harder next year I can take the age group...or get that slot..." Maybe what they need is to train smarter not harder, to reduce garbage work outs, to reduce injuries, or at least be able to train through them. Listen to the words of folks like Ben Greenfield, Gordo Bryn, Adam Zucco, or Mark Allen on Line to name a few on how to minimize your down time getting a hold on injuries and returning to plan as quickly as is safe. In other words, create your plan mostly with your head and not your heart. Come race season, maybe if you're lucky, anything will be possible.

Next week, back to business as the triathletes injury resource. Happy training everyone.

Thursday, November 17, 2011

Magic In Your First Race

Do You Believe in Magic?   Lovin' Spoonful

From USA Triathlon magazine *- With so much out there to read, I wouldn't be surprised to hear you missed this page.  I found these entries quite refreshing and thought I'd pass them along.

The Big Question: if you could go back and change one thing about your first multisport race, what would it be?

I would learn how to un-clip from my bike, so I wouldn't fall over and take down the entire transition fence...pre-race.  A. S. Atlanta, GA

I would not wear my mesh running shorts and non-moisture wicking shirt underneath my wetsuit.  After all, soaking up water like a sponge while flailing/swimming like an injured seal isn't much fun. Not to mention that my first race was the Chicago Triathlon.  J.S. Chicago, IL

Bring the correct tool to take my back tire off.  Ran 6 miles with my bike.  T.A. San Antonio, TX

Actually go for a swim in the ocean before the day of the race for my first triathlon. Boy, that was a surprise. Salt! Waves! People! Feet! No wall to push off! Pfew, it was rough. A.A. St. Petersburg, FL

Lost my timing chip and did not realize it until a buddy pointed it out 5 minutes before the gun. Ran back to the transition area, rifled through all my meticulously placed items - gone. Would I be allowed to race?  Sprinted back to swim "Start" and dived in. Found the timing chip under my bed at home AFTER the race.  J.E. Portage, MI

I wish I would have practiced running after riding my bike.  Needless to say I quickly learned why they call it a brick - my legs were as heavy as bricks.  I puked 4 times.  I was a mess. N.W. Locust Grove, VA

I would not have worn a Speedo.  It was like Dave.  G. W. Portland, OR

I wouldn't change a thing. The feeling I experienced when I crossed the finish line in my first triathlon is what got me addicted to the sport. Always been a cyclist. Hated running and now love it. Never could swim farther than 25 meters without stopping. now I can swim over a mile. Life-changing!   M.O. Mahomet, IL

*USA Triathlon Fall 2011

In my mind, there's so much information in print that if these authors had read some of the basic triathlon literature, they wouldn't have made these errors.  On the other hand, what better way to learn something than to screw it up?   And if pain or a little inconvenience is part of the lesson, it will be burned in one's brain forever.  I think that if you get out there, race, put it on the line, that each time you toe the start line you're a just a little more experienced. Before long you'll be the one writing the blogs!

With Thanksgiving coming up next week, do you already have a plan in mind where appetite control is king?  The temptation to graze all day is pretty strong at at our house and likely yours too.  Empty calories from too much alcohol, Aunt Mary pushing a third piece of pecan pie, that plate piled high with homemade chocolate chip cookies (any idea how many calories are in just one?*), plenty of snack food as you watch Green Bay and Detroit or the Fins take on the Cowboys in the late game. Just remind yourself, if Matt Fitzgerald, author of Racing Weight (and Iron War - terrifically written and  great Christmas present to anyone who "tri's") was sitting at the table next to you, how hard would he tell you your next work out would have to be to cancel out what's going in your mouth?

"A minute on the lips, a lifetime......"

*Calories in chocolate chip cookies vary widely from as low as 55 to over 200, with 8 grams of fat, for ones that are homemade with real butter.  Yum.  Just one cookie!

Sunday, November 13, 2011

Microfracture Update/74 Years of Triathlon Experience

Experience Counts For Sure


Joe Friel, USAT Coach #1* and Bob Scott, Kona Course Record Holder discuss tactics about 30 minutes before the gun in this years race in Kona. 
*Inaugural Co-chair of USAT National Coaching Committee.

Safety Note - I saw a gent riding his bike down the street recently, no hands, talking on his cell phone, paying absolutely no attention to what he was doing or the cars coming up from behind.  You talk about a recipe for disaster!  I'm hoping this is never you.

Microfracture Update - I've done a couple of blogs pertaining to microfracture in the past two years.  For those of you who missed them, it's a technique performed arthroscopically when the surgeon encounters a relatively small and contained area of arthritis, frequently performed during knee arthroscopy.

See:   Microfracture in the Triathlete, 3/7/09
          Osteochondral Autograft, 11/13/10

Briefly, the surgeon employs a tiny awl to make 2 mm holes in the arthritic area of the bone to stimulate a healing response.  The area is usually surrounded by normal healthy cartilage but the new tissue that forms after microfracture is more like a scar cartilage, one that will not be permanent , but may give the owner of knee a few more years of use.

Surgeons have tried a number of different options over the years to try and make this a life long repair. OATS, Osteochondral Allograft Transfer is one attempt.  It allows the operating surgeon to transplant normal articular cartilage from one part of the knee to another.  But, the indications are pretty narrow.

In this months Journal of Arthroscopy and Related Research a study by Steadman, et. al. discusses the use of stem cells (See my blog from 10/25/2011) to augment microfracture.  They note that "Arthroscopic and gross evaluation confirmed a significant increase in repair tissue firmness and a trend for better overall repair tissue quality..."  Although this particular study was done in horses, I suspect that further studies using a human model are right around the corner. Physicians have been harvesting stem cells (frequently from an area of the low back) and re injecting them for a variety of conditions over the years.  One such treatment is called Regenexx ( see www.regenexx.comm) where, for a host of conditions, the non-surgical use of stem cells seems promising in the short term.

74 Years of Triathlon Experience - As we head into the "off season," the opportunity to tremendously increase our knowledge base is here.  I've been involve with triathlon for almost 30 years and one of the things that strikes me is that we seem doomed to repeat mistakes made by others.  The training road you're charting now, to get you to the starting line at your first race in 2012 has been walked before you.  If you can simply learn from the encyclopedic experience of Gordo Byrn in "Going Long," or tri related weight control of "Racing Weight," from Matt Fitzgerald or "Your Best Triathlon," by Joe Friel, you'll be ahead of the game.  Way ahead.  Or, see if you can't find a triathlon seminar not too far from your home, particularly from someone you know little about, where the opportunity for learning something new is right up front.  Even Bob Scott and Joe Friel are searching for knowledge at this time of year. Barnes and Noble here I come.

Image 2, Google Images

Monday, November 7, 2011

2012, Your Best Year Yet? Dealing With Injuries.


Underpants Run, Kona, Hawaii 2011

"I don't know what I've been livin' on but it's not enough to fill me up.  I need more than just words can say, I need everything this life can give me."  Best of Both Worlds, Van Halen

In one sense, Van Halen is speaking (singing?) directly to the triathlete.  We give a lot to the sport, we get a lot from the sport.  But, if we can just take a minute or two off of that 40 K bike next year, then....who knows, maybe a tri PR!  For many of us, this time of year is a time away from triathlon.  A time where, like so many of the pro athletes, we take a complete break from swim-bike-run.  It's basketball, squash, water polo, golf, anything that's not what you do the other 11 - 11.5 months of the year.  A chance to cleanse the mind, fuel the fires for the future, and to dream about what might be in 2012.  Dreams are important.  Just ask Freud!

Perhaps your bike will resemble this one soon.

Preparing That Annual Training Plan With Previous Injury in Mind

Since it was below freezing on our bike ride this morning, much of the triathlon world is probably finished racing, fretting about next year and wondering where to begin constructing an Annual Training Plan, especially if a history injury is involved. Unfortunately, statistics would say that even if you've been involved in triathlon for just a few years, your probability of sustaining an injury is nearly 100%!  So now is the time, before you've done work out #1 preparing for the 2012 season, to review all available data from 2011 and see if you can both figure why your injury occurred and what you can do to avoid it (and others) in the upcoming year.

Running, of course, is the source of over half of triathlon injuries.  This is particularly true when twisted ankles or bike crash related type trauma is excluded.  And, in my mind, one of the hardest things in this search for causation is honesty.  Self delusion is a well practiced skill for those who race. "Well, it hurts, but not so much that I can't keep trying to catch that guy up there." (Sound familiar?)

But the athlete's whole focus is attempting to get their body to bear a greater load, to accept a higher level of stress for the same effort expended. Thus, greater speed is the outcome...and potentially a podium finish.  So, it's these changes in stress, increases at a tolerable rate, that get us there.  It's determining this rate of change that's the tricky part, however.  Why do you think there are so many stress fractures and other stress related injuries, etc. in our sport?

It's being honest in recognition of previous changes in routine.  Not just glossing through one's log thinking, "Oh, I should be able to handle this or handle that," when in fact you can't. And the change doesn't need to be Herculean. I've seen stress related injury after a single aberrant run.  For example, George goes to the beach and does his weekly 10 mile run in the hard packed sand, seemingly a soft (read non-concrete) surface and great idea.  But running out bound 5 consecutive miles at water's edge and back on the beach road, while softer on the feet, is really running 5 consecutive miles on the side of a shallow hill.  This is very different from the ever changing surfaces and angles that Georges legs see when he runs at home. Or, Sally is in Chicago visiting Aunt Minnie for Thanksgiving and gets fixed up with the local running group, all a tad quicker than Sally.  She executes her weekly 10 mile run with the group, pushed to her very limit, but quite satisfied at run's end with her "much better than I thought I could do" performance, her ability to draft, to keep up despite being near exhaustion, etc....until pain develops some time later.  It's not easy for the body to accept change.

Thus when planning for 2012, review the musculoskeletal changes that didn't go as you'd planned, include them in your thinking, maybe even talk it over with your "shoe guy" or other trusted advisor.  I've said in these pages before that the owner of our local running shoe store is the go-to-guy for running related problems locally. He's better than most all of the docs that I know.  If you run your plans by him (her) you stand a much better chance of not repeating the same mistakes next year.

They say that knowledge is power*. That's nowhere more true than in building an ATP. Good luck in your planning.  Maybe these folks from the Underpants Run (below) can help you.

*Or, in some circles, Ex Tridens Scientia. From Knowledge Sea power.