Tuesday, December 27, 2011

You Should/Shouldn't Become a Barefoot Runner

"It was somewhere in a fairy tale....."
                                                                    Taxi, Harry Chapin

Everyone is looking for that magic bullet, the one that will make them just a little faster on the bike, get them out of the water just a bit quicker or give them just a tad more stamina on the run.   I'm hoping that all of these searches are legal and don't involve performance enhancing drugs as the long term downside far exceeds the short term benefit.  (But people will always cheat, unfortunately.  This year in Kona one entrant "lost" his chip on the run and cut the course by 4 miles by not going down into the energy lab.  A few years ago one biker carried two timing chips, his and a friends, over the timing mat at the Hawi 56 mile bike turn around .  The so called Rosie Ruiz look-a-likes of triathlon.
                                                                                                                                (She was the woman who crossed the finish line as the winning female in the 1980 Boston Marathon but looked "remarkably sweat-free and relaxed as she climbed the podium to accept the winner's wreath" by the New York Times.)

So, in addition to training harder or differently, we look in other directions for not-so-free speed, and is the barefoot running movement the one for you?  (In this piece, the term barefoot refers to both absolutely shoeless and to the glove-type running apparel but not to the array of minimalist running shoes which have their place and can work for some types of runners.)

Barefoot?  Well, it depends. First, if you've read this blog before, you know that one of the primary goals here is to reduce the injury rate in training and racing. You've also seen that the published injury rate is over 50% in everyday runners and approaches 90% in those training for a marathon each year!  Barefoot running is said to diminish this stat in a number of ways from strengthening the foot musculature and by making the runner a forefoot or mid foot striker as opposed to the heel striker which so many of us are.  In other words, the change in foot wear is said to lead to a change in running mechanics and the shoe may get some but not all of the credit.  There is also frequently a cadence change with this.  The thought is that increasing one's stride rate decreases the stress the limb bears as does forefoot or mid foot striking.  In short, the lower limb becomes a more efficient shock absorber in this manner than that of the heel striker.  If you were to watch the stride rate of elite runners such as the Kenyans, you'd see that they take in excess of 180 strides per minute, 90 per leg/minute.  This is easy for you to determine for yourself by counting the number of times the racer strikes the ground with his/her right foot in 20 seconds.  Then, if you don't already know your own rate, count it out on your next run to see where you stand.  Is there room for improvement?

These glove-like shoes like the Vibram 5 fingers have not been on the market long enough to give an accurate picture as to their long term effects, both positive and negative. And, transitioning to them is not done over night but rather over a period of months rather than days.  Anything more quickly and the potential rate of injury could be higher rather than lower.  Joe Friel in the Triathletes Training Bible suggests that if contemplating this change from heel striker that you "Save this change for the next Prep period of the training year when run durations are short, and at first run only on soft surfaces such as grass, dirt or a track, allowing plenty of time for recovery between runs."

Runbare.com suggests that when making the barefoot transition that "...it takes time. If you do too much before they’re ready, you risk tendonitis, muscle tears, strained ligaments, or stress fractures. To avoid all of this, you need to go slow, and consider tiny distances to begin with." Understand they have a bias and want you to buy their book.  The other side of that coin might be the assistant manger of one of our local running shoe stores equipped with years of experience dealing with all types of running shoes and runner's problems states "I NEVER recommend Vibrams and try to dissuade everyone who walks in the store asking for them." This is not true of other minimalist footwear. Or, David Westerdahl, MD, an Orthopedist of the Cleveland Clinic who feels that "One final thing to consider is by the time many triathletes exit T2, they are running on fatigued legs, trying to survive to get to the finish.  In my opinion, unless you've done extensive training to adapt your form and condition your feet to the changes of barefoot running, the final leg is not the best time to run barefoot."

I'll leave you with a few quotes from the November 2011 Barefoot Running Round-table in London called "Natural Running - advantages and disadvantages." 

1) Prof Benno Nigg, a world leading biomechanist, asks his students this question in a final exam: "Does barefoot running prevent injuries?", and the only answer he accepts for a good grade is "I don't know because we don't know."

2) Dr. Ross Tucker, Science of Sport, noted that "barefoot running is, at it's worst, a good training modality that may have benefit for running performance."  But, "There may be people who simply cannot adapt to barefoot running....shoes may be the only thing enabling them to run."

"People who have run in shoes for many years do NOT run barefoot the same way as people who have been barefoot for a long period."

Conclusion - "we need future research to help us fill in the spaces between what is known and what needs to be known." 
***If you as the athlete are willing to virtually start over with your running in your transition to barefoot running, then you have a good chance of making it work for you.  But, if you only have a couple of months to effect change, barefoot running may lead to further injury and may not be your best choice.

Image #2, Google Images, New York Times

Sunday, December 18, 2011

Frostbite Avoidance, Dressing for Winter Training

"With the right gear you can put a man on the moon.  There's no such thing as bad weather, just bad gear." 
                                                 John McGuire, Former Navy SEAL

If this is your first winter training outdoors this post can make a big difference in your comfort and safety level.  Although it may not seem like it, the right choice of clothing and equipment can make the Winter run or bike every bit as enjoyable as Spring. In previous posts I've discussed the importance of being seen by traffic, fresh batteries in your bike rear strobes, running reflector vest or belt light, etc.

Frostbite is entirely avoidable with just a simple understanding of what it is and measures to take to reduce the possibility of suffering it. Blood has to travel a long way from the heart to get to the hands, feet, nose, ears, etc.  These locations at at the greatest risk for suffering an injury due to cold.  When the exterior temperature is below freezing, with inadequate protection, the exposed (or improperly protected skin can literally freeze.

With Winter training comes the need for covering body parts balanced with maintaining mobility. Couple this with the reflex constriction of these peripheral blood vessels shunting blood away from the fingers and toes to the muscles and organ systems.  Frostbite begins to occur when these digits actually begin to freeze and then we see the skin die due to lack of oxygen from the loss of blood supply.

Frostbite is frequently divided into two groups, superficial and deep.  On the superficial side, the athlete notices itching, a burning or tingling feeling, and likely even numbness.  For those suffering from deep frostbite all sensation is lost, the skin turns a whitish purple color and blisters form.

With rewarming, pain is the hallmark of both as the flow of blood is returned to the area.  This pain can sometimes be considerable.  It's said that this progresses to a deep aching type pain which can last for many days.  Initially, oftentimes the patient doesn't have the appearance of one with a significant problem but as time passes, the full extent of the damage can be realized.

Not all cases of cold exposure damage are as significant as the above, some merely experience frost nip or chilblains.  Any symptoms such as tingling or numbness resolve (but not without some pain) when the tissue is rewarmed. I'm certain that many of you who live and train in the cold have experienced this.  I know I have.  Lastly, hypothermia frequently accompanies these problems, and if severe is more important to address than the skin.

Prevention is, of course, the most desirable pathway. As athletes who train in sub freezing conditions, knowing that this is a risk can be a big help.  I read that frostbite sufferers share the "Unwillingness or inability of the person to remove himself or herself from the threat." In short, dress for the expected weather conditions! You can be both comfortable and visible throughout the winter months. If you simply check the weather forecast as you plan your workout the night before, and then the morning temperature before you head out the door (an inexpensive thermometer outside your bedroom or bathroom window does the trick as it can be considerably cooler at your house than where the TV station gets their reading.)

Then, think of your core dressing in layers with a goal of staying dry by not using cotton next to the skin as it absorbs moisture (sweat). Any of the light weight technical poly fabrics that wick away moisture will do nicely. Then a layer or two of a long sleeve technical shirt under a wind resistant jacket, usually not Goretex as it can be too hot, and you're set.  Know that your first moments outside will be a little chilly but once you crank it up you'll be toasty.  For your hands, think wind resistant, possibly mittens.  Some will wear gloves under, some - like those with Raynauds (see previous blog posts) - will use chemical hand (and feet) warmers but this will become automatic with a little experience.  As for your feet, running shoes with a skosh more room and Smartwool socks are great.  If you're considering going out in slippery conditions like fresh snow, think about a pair of inexpensive Yaktrax which act like mini spikes.  Lastly, we can lose a lot of heat through our heads.  You can experiment with a fleece cap, or simply a generous head band over the ears to see what you require.  With just a little practice, you'll see what works for you at particular temps, and be able to safely and comfortably train outdoors all winter, every winter.

Wednesday, December 14, 2011

Bike Hygiene, Puhleeze! (And How To Pee On a Moving Bike)

"Life is a highway. I want to ride it all night long." Rascal Flatts

Each of us thinks differently about that two wheeled machine we spend so much time on in training.  We spend hours making sure that it's in peak condition at the start of a race so we don't have a bike related mechanical issue.  It's our platform for our nutrition plan.  It can also be the site of emptying one's bladder, something learned the hard way (following too closely) in draft legal races.  I present to you a few before and after images to show how some spend their 112 miles and whether you think their nutrition plan a success or not.



If you're just a little tired of Christmas music, you'll really enjoy this a Capella men's group from a few years ago.  They're simply remarkable.  http://www.youtube.com/watch?v=2Fe11OlMiz8

Peeing on a moving bike.
When I was standing in the registration line of an Iron distance race a few years ago, I saw a man about my age and we began talking race strategy in this very slow moving line. When I asked if he thought he'd need to stop to pee over the 112 miles, he exclaimed, "STOP!? Why would I do that?" He then went through the details of how to get this bodily function accomplished.  When you're on a downhill, stop pedaling and put most all of your weight on the pedals.  Then relax, and just go.  And according to him, just a little "Swish, swish, swish with your water bottle" to the crotch of your bike shorts, and you were done.  Hmm, sounds simple enough, how could it possibly go wrong?  

I'd watched videos of the riders in the Tour de France coast to the back of the peleton for a "comfort break" per Paul Scherwin, undo their bike shorts and just hose down the curb, the trees, race fans, cars, whatever happened to be there as the group was going 30 mph.  It didn't seem like something I was interested in but this new method seemed more civilized and if things worked out right you could still PR on the bike.  Cool!  I tried it on race day and it worked great.  In fact, I may have been a little over hydrated as I was able to "practice" the technique a couple times.

One suggestion.  Wash out your bike shorts immediately following the race.  I did not.  In fact, I packed my bike to run bag just as I had picked it up from T2 into my suitcase.  And to make things worse, when I got back home, I just took all the tri gear and threw it outside on the screened-in back porch to get to it another day.  Well, we all procrastinate sometimes.  After about two weeks, my spouse decided to "help" me with cleaning up my stuff.  Bad decision. When she opened this particular bag, in the words of Gilda Radner as Roseanne Roseannadanna, 'I thought I was gonna die!"  Apparently, it let out the aroma of ten dead skunks, or worse!  Maybe eleven!  Her only possible course of action (she said) was to throw it all in the trash, "Life is too short, John," which I heard about four times during supper. I decided that the safest course was to not complain about the loss of bike clothing and merely say thanks.  I wash out the "new" bike shorts now.


I was asked by the American Academy of Orthopedic Surgeons to pass the below along.

Legislative Alert – New Good Samaritan Protection Bill Introduced
Protect Patients Now needs your help in support of an important, bi-partisan bill introduced last week in the US House of Representatives.  Contact your Congressman today to ask him to cosponsor H.R. 3586, the Good Samaritan Health Professionals Act, to ensure patients have access to vital, on-site medical services in the wake of a natural or man-made disaster.
As the nation witnessed during Hurricane Katrina and other recent disasters, there was a critical shortage of medical volunteers on the ground to assist those in need. Due to inconsistencies in federal and state laws, these volunteer health care professionals have been turned away or limited in the scope of their assistance because of the threat of medical liability lawsuits.
The Good Samaritan Health Professionals Act would help protect medical volunteers from lawsuits during a large-scale disaster, and ensure that vital health care services are available to disaster victims.

Image #9, Google images

Sunday, December 11, 2011

The Female Athlete Part 3, The Pregnant Athlete

"You got to do what you can, and let Mother Nature do the rest." 

A great look in the 2011 Kona Underpants Run.

The Pregnant Athlete

The most important aspect of athletic participation during pregnancy is the level of physical fitness prior to conception.  The greatest concerns for activity during pregnancy include:

    Effects of elevated maternal temperature on the fetus.
  • Effect of exercise on blood flow to the fetus.
  • Effects of exercise on the weight of the fetus.
The benefits of exercise during pregnancy include weight control, improved muscle tone, self-esteem, decreased incidence of varicosities, decreased incidence of back pain and decreased incidence of sleep disturbance.  The following is a summary of the American College of Obstetrics and Gynecology guidelines for exercise and pregnancy.

Direct Contraindications to Exercise During Pregnancy

Pregnancy induced hypertension
Preterm rupture of membranes
Preterm labor during the prior or current pregnancy
Incompetent cervix/cerclage
Persistent second or third trimester bleeding
Intrauterine growth retardation

Recommendations About Exercise During Pregnancy

1.      During pregnancy, women can continue to exercise and derive health benefits even from mild-to-moderate exercise routines.  Regular exercise is preferable to intermittent activity.

2.      Women should avoid exercise in the supine position after the first trimester.  Prolonged periods of motionless standing should also be avoided.

3.      Women should be aware of the decreased oxygen available for aerobic exercise during pregnancy.  They should be encouraged to modify the intensity of their exercise according to maternal symptoms.  They should stop exercising when fatigued and not exercise to exhaustion.  Weightbearing exercises may under some circumstances be continued at intensities similar to those prior to pregnancy throughout pregnancy.  Non-weightbearing exercises such as cycling or swimming will minimize the risk of injury and facilitate the continuation of exercise during pregnancy.

4.      Morphologic changes in pregnancy should serve as a relative contraindication to types of exercise in which loss of balance could be detrimental to maternal or fetal well-being.  Any type of exercise involving the potential for even mild abdominal trauma should be avoided.

5.      Pregnancy requires an additional 300 kcal/d to maintain metabolic homeostasis.  Thus, women who exercise during pregnancy should ensure an adequate diet.

6.      Pregnant women who exercise in the first trimester should augment heat dissipation by ensuring adequate hydration, appropriate clothing and optimal environmental surroundings during exercise.

7.      Many of the changes induced by pregnancy persist for 4-6 weeks post-partum so exercise routines should be resumed gradually based on a woman’s physical capability.

In conclusion, the need for the physician to understand the unique aspects in treating female athletes is paramount.  Adding these insights to primary care will only improve diagnostic and treatment efficiency.  Certainly further research is needed to better understand increased knee injury incidence in females compared to males.  Also the observant eye for diagnosing the female athlete triad is the first step to initiating early and more successful treatment in a syndrome where the patient and those around her are prone to avoidance and denial.  As a physician, guiding exercise and athletic activity through all ages and even during pregnancy of your female patients will be rewarding to your practice and empowering to your patients.

Recommended reading:

American College of Sports Medicine Position Stand on The Female Athlete Triad at www.acsm.org
Ireland, Mary Lloyd and Ott, Susan M. Special concerns of the female athlete.  Clinics in Sports Medicine 23 (2004) 281-298.
Exercise During Pregnancy and the Postpartum Period. ACOG Technical Bulletin 189.  Washington, DC: American College of Obstetricians and Gynecologists; 1994

Again, great thanks to Bill Vollmar, MD who presented this material in 2008.

Wednesday, December 7, 2011

Off Season Tri Alternative, SEAL Physical Training

"And now, for something completely different." Monty Python

Many sources talk about variety, change of pace, do something other than swim-bike-run at this time of year and I agree.  This is an article I wrote for another publication that I've modified for this audience.

Fellowship among triathletes is not often discussed in the realm of intervals and Power Taps but for many it's an important part of their tri experience whether they realize it or not. I wholly agree.  Triathlon can be as important to one's mental health as physical fitness.  Starting one's Monday work week work at the pool, discussing the  events of your lane mate's weekend, and arriving at the work place with wet hair and a smile on your face feeling eager and refreshed make you a better employee.
I'm convinced.

How I Know Today Is My 64th Birthday?

“They won’t talk to you unless you’re in push-up position.”  It was with these words of encouragement that I joined my son Ben at SEAL Team Physical Training a few months ago.  STPT was started in Richmond, VA several years back by a former Navy SEAL who had ideas on making those around him stronger and fitter.  And he needed a job.  It worked well enough that there are branches here in Charlottesville, Richmond, Washington, DC, and they’re in the process of setting up in other metropolitan areas. We meet every weekday morning at 6:15, come rain, come shine, come whatever, and heaven forbid someone’s late.  It becomes an “opportunity to get stronger.”  The group pays for individual shortcomings - we get to do push-ups.  Only 20 or so if the instructor is in a chipper mood, 30 or more if not.  Usually it's not.  Then we go for a warm up run.  Often times it’s the old indian file which I hadn’t done since high school.  And that was a long time ago. Following our run, the group could do bear crawls, sit-ups, more push-ups, pull-ups, inclined sit-ups on the side of a nearby hill, crab soccer tag, did I mention more push-ups?, sprints, etc.  At the end of the hour, the group of 40 – 50 is a bit tired, has had a great work out, and is generally smiling and chatting actively.  In fact, their first question is commonly, “Where is the work out tomorrow?” We never do the same work out twice. And at approximately two month intervals we do the Navy Physical Strength Test to get an accurate idea of where we stand.  What’s really encouraging in this self-paced work out is there are all sizes and shapes of participants from those who run 7 minute miles to some who started the class being unable to do even a single sit up.  But on the days we do the PST, virtually everyone can see personal improvement.  A sincere effort is made to recognize this improvement in each individual, identifying them by name and accomplishment.  And the gent who couldn’t do a sit up a few months ago?  He managed 19 of them at a recent PST. A feat for which he received tremendous support and positive feedback from the group!

Fellowship among adults is not often easy. Sure, when you’re part of an athletic team or large company there’s always a softball game or touch football on Sunday afternoon.  Unless the Packers are playing of course and then it’s a different kind of fellowship.  But, outside the service or business work place, friendship is not guaranteed.  In fact, it can be quite a surprise to those used to the camaraderie of the office lounge.  I remember quite vividly the comments of a friend who was quite used to his superior military position carrying over to his community life, easy recognition and great service at the establishments in town.  But when he retired and moved to a new community, he was most dismayed to report that at the barber shop, “I was just next retiree in line.”

We come from a culture that rewards fitness.  Our chosen avocation has done likewise.  Is there any reason that we couldn’t continue to lead by example?  Or, should we – as has happened to many who show up a little late for our high school class reunion dinner parties – walk in to a group of classmates and think, “I must be in the wrong place, these are all old people?”               

As a physician, I see people from all walks of life in my office, many who’ve discarded any sense of commitment to exercise.  I’d say we started off our careers with a higher sense of fitness than most.  I’d also vote that we make the effort to stay that way.

Here in central Virginia, we’re surrounded by parks with lakes.   Boats play an important part of teaching teamwork, an essential in STPT.  The inflatable Zodiacs and kayaks also add to the variety.  The Zodiac races are  something to behold.  Not pretty, but exciting.  Splashing water, cheering voices, boats heading in a variety of  different directions, many not close to the intended course, and the occasional man overboard drill when  someone misses a stroke.  Since many of the work outs begin before dawn we’re on the water in the dark.  It’s quite a challenge to jump overboard, dressed, with a life preserver on and swim under the craft, hand over hand, feeling the ribs on the bottom of the boat, when it’s pitch black.  But, when you do bob up on the opposite side, it gives you a real sense of accomplishment.  As you’d expect, this task is more difficult for some than others but if you begin to fail, in this or any other aspect of STPT there’s always someone nearby to help you out.

While floating next to the boat once, I made the mistake of retying one of my running shoes, totally by feel.  When this “infraction” was noticed, I was asked by Instructor McGuire, only half in jest, “What’s the matter?  Didn’t Mommy and Daddy teach you how to tie your shoes right?”  (I always double knot them now.)

So how did I know it was my 64th birthday?  Well, we started off today’s workout with 64 push ups and one to Beat Army of course.  Little did these people, most in their 20’s and 30’s know what was coming.  They’re quite used to birthday push ups – for people their own age – but as we passed 40…and then 50, from the back of the crowd came a loud, “So how old are you anyway?”  That voice did 14 more push ups, and one to beat Army!

Over the course of the work out, I had 40 or more “Happy Birthdays.”  And I worked up a sweat, all by 7:15 am.  Imagine starting your day this way.  Every day.

So if SEAL Team Physical Training comes to your town, be the first to sign up.  Or, you know how this works, start one of your own.  It’s more rewarding than you might imagine.  And besides, man overboard drills in a Zodiac are fun.


Photographs: Nick Strocchia ([email protected])

Sunday, December 4, 2011

The Female Triad, Eating Disorders, Amenorrhea, Osteoporosis

"It's not having what you want, it's wanting what you've got"
                                                                  Sheryl Crow

Only the run to go.

Last week we started a 3 part series on the female athlete and covered some of the physical and physiologic differences between male and female athletes.  Injury patterns and the contributions of estrogen and ligamentous laxity were also discussed.

This week the so called female triad is considered including eating disorders, amenorrhea and osteoporosis.  I first broached eating disorders in the female triathlete in a blog I wrote for Mother's Day 5/21/2011 and it has become my single most widely read blog.  Somebody out there thinks this important.

The Female Athlete Triad
Amenorrhea, disordered eating and osteoporosis define the female athlete triad.  Although found at all levels and types of sports activities, the female athlete triad is more prevalent in sports emphasizing prepubertal  body type, perfection, thinness, revealing clothing and subjective judging.  These sports include dancing, cheerleading, gymnastics, figure skating and distance running.  These females tend to be in high pressure environments set up by coaches and parents.  They tend to show driven personalities.  They have poor nutrition knowledge and tend to be in families with history of eating disorders and abuse.  The earlier the diagnosis is made the more likely treatment will be successful.  Any female athlete showing one part of the triad should be evaluated for the other two parts immediately.  The true prevalence of the female athlete triad is unknown.

Disordered Eating
Disordered eating refers to a wide range of ineffective eating behaviors used to lose weight or achieve a lean appearance.  This in itself is a multifactorial problem based on issues ranging from requirements for specific sports to disturbed self image.  In non-athletes the prognosis for treating an eating disorder is poor with 50% doing well, 30% relapsing and a 10-20% mortality rate.  There are no studies specific to female athletes.

Restrictive eating behaviors such as voluntary starvation and binging-purging behaviors are only part of this problem.  Many athletes will just not eat enough to deal with energy requirements for athletic activity.  Severe caloric restriction reduces metabolic rate and causes changes in all organ systems.  Anorexia nervosa is the diagnosis when the patient views herself as overweight and restricts eating even though their weight is 15% below ideal body weight.  Amenorrhea is one of the DSM-IV criteria for this diagnosis.  Bulimia is a cycle of food restriction followed by overeating then purging.

In general eating disorders should be viewed as chronic illness with serious medical and psychological results.  Treatment requires a long term multidisciplinary approach involving physician, mental health practitioner and nutritionist.

The long recognized cessation of menses with physical training was felt to be based on low body weight and low body fat.  This is now known to be untrue.  More recent studies have shown that exercise stress and energy availability both can cause disruption of the GnRH pulse generator and the subsequent decrease in LH as a more likely source for amenorrhea.  The exercise stress hypothesis is based on high resting cortisol levels and blunted cortisol responses to exercise in amenorrheic athletes.  The low energy availability hypothesis follows studies where eumenorrheic trained women showed suppressed LH pulsatility after 3 days of training while dietary intake was reduced, but not suppressed when dietary intake was supplemented.  Several other studies have supported these findings.

Amenorrhea is the easiest symptom to recognize in the female athlete triad. Exercise associated amenorrhea is a diagnosis of exclusion.  Reversal of amenorrhea is unpredictable so all women should be screened for pregnancy as part of their workup.  There is an observed decrease in bone mineral density in non-menstruating athletes which predisposes them to stress fractures and osteoporosis later in life.  Calcium supplementation of at least 1500 mg a day should be encouraged in amenorrheic women.  Treatment for athletic amenorrhea should begin after missing 3 consecutive menstrual cycles.  If the athlete is within 3 years of menarche, treatment should involve decreased physical training and supplemented nutrition.  If the athlete is 3 or more years post-menarche, low dose oral contraceptives should be considered.

Osteoporosis is characterized by low bone mineral density (BMD) and microarchitectual deterioration of bone tissue.  Studies confirm higher incidences of injuries and stress fractures in amenorrheic and oligomenorrheic as compared to eumenorrheic athletes.  Since the female athlete triad occurs during the most important years for women to build their maximum BMD, the question becomes whether this problem can be reversed.  Several studies do report increases in BMD in amenorrheic athletes resuming normal menses but these gains may be limited.  Amenorrheic athletes using hormone replacement therapy at doses used in post-menopausal women have shown maintenance of BMD but no gains.  Weight bearing exercise has a positive effect on BMD but it is not a large increase.  The positive effects of weight bearing exercise in amenorrheic athletes are negated.  Athletes suspected of the female athlete triad should undergo DEXA scan to confirm BMD status.

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 1983...be 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!