Sunday, April 29, 2012

Key Principles of Open Water Drafting/Swimming Core Exercies

A crash in California almost took her leg. A bomb blast in Iraq helped save it.

Today, about 70 percent of war wounds are musculoskeletal injuries and 7 percent of those with major extremity wounds also sustain loss of limbs. Trauma surgeons’ war experiences make lasting contributions to orthopaedic surgery, benefiting not only the troops but also civilians around the world. Those contributions also helped save Dominique’s leg. In fact, her orthopaedic surgeon says that his experience treating war wounds as a military surgeon armed him with the skills to treat Dominique.

Getting a triathlon off to a good start by a successful swim may not guarantee a PR but it's always a great way to start.  In one of the swim publications I picked up, a piece by Steven Munatones sounded most helpful. I'll present if here with mild editing as I feel it informative to those of us who struggle in open water.

Cyclists, race car drivers and open water swimmers all know the benefits of drafting and positioning.  As swimmers take off in an open water race or triathlon and go from buoy to buoy, they create a conga line with seemingly everyone chasing after the person in front of them.  Where ideally should you position yourself?  It helps to know a bit about water movement.

The Ideal Draft

    A swimmer in the open water is essentially a displacement vessel.  The bow wave created by a swimmer has forward and lateral movement.  These waves move at an angle relative to the direction of the swimmer and are based on the swimmers speed and size.  There are three key facts to keep in mind;

   1. The faster the lead swimmer, the better your draft will be with all other things being equal.
   2. The physically larger the lead swimmer, the more beneficial the draft is for those behind.
   3.  The closer you are to the lead swimmer, the better your draft.

The Perfect Position

    It's a fact known by world-class swimmers: drafting between the ankles and hips is more beneficial than drafting directly behind the lead swimmers for various reasons.

   1.  When the drafting swimmer reaches near mid-body of the lead swimmer, the lead swimmer's wake (i.e. spreading the bow wave) has moved laterally, so the drafting swimmer can take maximum advantage of the bow wave.  That is, the drafting swimmer has reached the center of the complete wave created by the lead swimmer.  Basically, the drafting swimmer is surfing a bow wave.
   2.  The most efficient drafting is achieved if you cruise at the same speed in the wake of the lead swimmer off to the side - but away from the eddies caused by their kick.
   3. In the middle of a race, when the kick of most swimmers is less than the end of the race when they're sprinting, the optimal draft position is slightly different.  At the end of the race when the kick increases, swimmers create swirls by their kick.  The more swirls, the more drag. So if your opponent's kick increases, move up higher along side their body to utilize their bow wave, but far enough away from the eddies and swirls caused by their kick.
   4. If you swim along side the lead swimmer, you do not have to lift your head so often to navigate.  This saves energy that can be utilized at the end of the race.  If you swim directly behind the lead swimmer, you must often lift your head to confirm your direction and position.
   5.  Even if the water is clear and you can easily see the lead swimmer under the surface of the water, your head is in a sub-optimal position.  The most optimal head position is when you are looking straight down.  This creates a more streamlined and efficient body position, saving you energy and creating less drag.
    There are a number of other factors that come into play when drafting and positioning but these basic factors are enough to get started.

I have always felt that dry land training makes us better athletes as well as decreasing the tedium of tri training.  There are many ways to accomplish  this from reading the Triathletes Training Bible, talking to a swim coach or strength & conditioning trainer, or in this case Youtube.  I picked this video for it's simplicity and sincerity but you're welcome to look for others.

Image #1 AAOS
Thanks to Steve Munatones

Sunday, April 22, 2012

MASH - A Movie Before the TV Show? Triathlon History

"Through early morning fog I see, visions of the things to be,
the pains that are withheld for me, I realize and I can see..."
                        Suicide is Painless, Johnny Mandel  (Theme to MASH)

Did any of this well known cast come from the original movie?
It's important to understand our triathlon history.  By history, I'm not only referring to the contributions of John Collins, Scott Tinley, Dan Empfield, Bob Babbitt and Joe Friel, but of the more recent experiences of everyday Joe Athlete who's walked the road you're on before you.  USAT thinks that this is important enough that it's the very first thing taught in the Coaching Certification Course for would-be coaches. In the words of George Santayana, "Those who cannot remember the past are condemned to repeat it."

I met a young woman recently who had no clue that the TV show MASH had come from a very successful movie by the same name, and the movie from a book by Richard Hooker (actually a pseudonym for a surgeon named H. Richard Hornberger.) 

One of the reasons this truth hits home in the triathlon world is the very common tri forum post, "I just was looking at buying some of those new xyz carbon wheels and wondered if anyone had any experience with them?"  Or you noticed that in your last sprint tri, the athlete next you in the transition area finished the swim well behind you but managed to exit T1 well before you and you figure that cutting time off your transitioning is needed..  All you have to do is go to You Tube for videos like and after a few practice sessions in the driveway - yes, the neighbors will stare at a woman in her wet suit standing next to her garbage can in suburbia but this is one of the small costs of excellence in triathlon - you'll be the queen/king of T1 and T2.

A terrific place to learn new things is the transition area before the race. Triathletes are proud folks and many like to talk.  I do pretty well in my age group and I can't tell you hoe many times a complete stranger will approach me and ask something like, "How come you have so few items in your transition set up?"  I then go right back to the video above, experience and the particulars of this specific race and we have a good give and take.  Just as often, I'll learn something from them like, "Well if you were to place your bike over there for this particular race you'll avoid much of the foot traffic."  This is also very true at races end before the finishers party when everyone is full of themselves, their accomplishments, and relaxed.

In short, take the time to read, to talk, to quiz others, understand the "history" of your sport and it's intricacies and you'll be faster,  For sure.

Wednesday, April 18, 2012

Injections for Triathletes, What You Need to Know

"We must all suffer one of two things: the pain of discipline or the pain of regret and disappointment."   Jim Rohn

Black Cat Firecrackers

This blog will both start and end with a quote from Jim Rohn, a motivational speaker who passed away a few years ago, and just seemed to have a knack for self-motivating people in the right direction.  We need to pay attention to the teachings of others so that we can learn from their mistakes without having to repeat them ourselves.  It's part of the educational process. 

I think that's why we read blogs like this one.
A mistake I made a few years ago, compounded by a failure of the TSA, involves firecrackers.  Lots of firecrackers!  While away from home, I'd purchased a "brick" of lady fingers, 1000 of the ones you see above, and just threw it in the bottom of my backpack for later use.  I forgot about them.  A couple weeks later I packed up for the trip home, a journey which would involve two flights.  In the middle of the first, I was looking for a book to read, when I thrust my hand deep into my backpack to find, yep you got it, 1000 firecrackers!!  Had I gone through the TSA screening metal detector and my backpack the conveyor belt x-ray unit?  Of course.  So I showed the brick to my teenage son as we tried to figure out what the right thing to do was.  We felt that to admit to the possession of 1000 firecrackers while in mid flight would be to risk incarceration, or worse.

The option we chose was to keep our mouths shut, it was an honest mistake!  We never got caught nor were we accused of being "Regular Law Breakers" as Thomas The Train might have uttered.  We were lucky.

I haven't made that mistake again.

Bursitis?  Tendinitis? Arthritis?  Injections can be recommended for a host of musculoskeletal problems and different types have different roles.  We hear about cortisone (steroid - corticosteroid, not to be confused with the anabolic steroids body builders might have, at one time, used to bulk up), PRP or platelet rich plasma, and finally viscosupplementation.  I've written about some these individually in the past like PRP (in pretty significant detail) for Golfer's Elbow (or Swimmer's Elbow as it would be called in this community) but will try to sum these up to make it easier for the reader.

The first thing to remember is that not all of the above injections work for all problems.  Since cortisone has the widest reputation, it seems to work most effectively in cases of acute inflammation. But when applied to tendon related problems, so often the root cause of the issue is a chronic tendinosis, that it proves ineffective or worse.  Lateral epicondylitis or Tennis Elbow is a good example of this where a chronic problem treated with an injection, better for a while, is actually made slightly worse over time.

When considering Plantar Faciitis on the other hand, a study by the American Foot and Ankle Society showed improvement with cortisone injections which lasted over time.  In those patients where PRP was chosen for injection, while they did not get the immediate relief of cortisone, over time they equalled then exceeded the level of relief seen with cortisone.  Achilles Tendinitis is helped by neither, and many practitioners are very hesitant to inject either the Achilles or Patellar Tendons - with very good reason..  When dealing with Rotator Cuff issues, the jury is still out as it's effective in some but not in others. There's no indication that it worsens the problem.

For those triathletes with arthritis, both cortisone and the viscosupplementation products have a role.  These can be a series of injections, usually of a hyaluronic acid type gel preparation, with a goal of long term help.  I've used it for both knee and shoulder arthritis for many years with predictable results.  I know of at least one study where it was used in the ankle joint but was not found to provide the desired outcome.  Importantly, in the case of arthritis of the knee, many have asked that I perform a "clean up arthroscopy" so that they can return to pain free training and racing.  It's worth remembering that unless there's some type of mechanical problem with the knee such as a torn meniscus, procedures such as these only help for a short period.

In short, depending on your particular problem, it's acuteness, and the experience of your health care team, there may be a role for one or more of these products in the future.  Plus, medical knowledge and experience are constantly changing so these indications will likely expand over time.

And closing with an applicable quote from Jim Rohn as promised.  I think this is particularly aimed at the multi-sport athlete who plans and executes a training plan every day.

"Failure is not a single, cataclysmic event.  You didn't fail overnight.  Instead, failure is a few errors in judgement, repeated every day."

Good luck to all!

Tuesday, April 10, 2012

Shoulder Pain, the A,B,C's/Sports Docs

"Gutting it out in the Triathlon

Too many heartbreak hills have been conquered by too many dentists - the marathon isn't the ultimate challenge anymore.  Even before fitness became a way of life for millions of Americans, in fact, restless runners were probing beyond the 26.2 mile limit, experimenting with more ego-boosting endeavors.  A swim around Manhattan Island, say, or a bicycle ride up Pike's Peak.  Now we have a whole new class of athletes: men and women who swim 2.4 miles, cycle 112 more and then run a marathon, pausing only to change clothes and scarf a banana. Call them triathletes, endurance buffs or just plain foolish, their crudely cobbled-up specialty -- the triathlon --may well be the fastest-growing participatory sport in America."
                                                                            Newsweek November 7, 1983

Check this athletes foot wear, or lack there of.  Strong gentleman!

Shoulder Pain

While most frequently the source of shoulder pain lies within the shoulder itself, we must keep an open mind for other sources of distress, some relatively rare.  Below is a brief list of some of the more common reason shoulders may give you some pain.  If you're suffering more than just an occasional ache, Sports Docs like P.Z. Pearce (pictured below), Director of the Ironman Sports Medicine Program in Hawaii and resident of Spokane, WA or Bill Vollmar of Lancaster, PA may be the type of doc you want to see.  Previously, the recommendation might have been toward an Orthopedic Surgeon but non-surgical docs like P.Z. and Bill are all over the country and for those who think their physician might be knife happy, these guys are perfect.  They have an intense interest in the well being of athletes and the knowledge base to back it up.  And, if you ultimately fail conservative care, only then would you be referred to the surgeon.   Sounds good to me.

Bursitis    Very common among endurance athletes.  Bursitis can be elbow, heel, shoulder, hip, etc. Any place where there is force between two soft tissue structures and the force applied exceeds the bursa's ability to transmit this pressure. Occasionally treated with an injection.

Arthritis   Age related. Wear and tear degenerative change.  The articular cartilage at the bone ends begins to wear.  This can be an irreversible condition, and in some, put a real damper on their triathlon career.  Some would casually say, "well have it replaced."  I'd expect a shoulder replacement to be the death knell in one's tri career.

Dislocation   The head of the humerus (ball part of the ball and socket joint ) "pops out" as I've been told many times, of the joint.  Dislocations happen to a number joints including shoulders, hips, fingers, toes, etc.  The dislocation must be "reduced," or put back in place, sometimes requiring anesthesia.  Recurrent dislocation frequently leads to surgical repair.

Frozen Shoulder  Stiff shoulder, adhesive capsulitis, just some of the many names of this benign condition found more commonly in women than men. There's usually no trauma, the joint gradually loses motion, and the patient realizes she can not longer fasten her bra in back, reach over head, etc.  It commonly takes a good while for this to resolve, even with cortisone injections into the bursa and the joint.  A small number will end up in the operating room for what;s known as a manipulation under anesthesia or even an operation.

Separated Shoulder  Trauma, falling off a bike or from a height leads to a disruption of the ligaments at the outside end of the collar bone.  There are several grades of injury, the more severe of which describe the collarbone sticking up an inch or more giving the joint a very asymmetric appearance. That said most of these do not require surgical repair except under relatively infrequent conditions.

Bicep Tendon Rupture  The bicep tendon, as the name implies, has two heads, and occasionally the long head of this muscle will rupture.  This can be associated with rotator cuff failure but when an isolated problem, the tendon tears from inside the joint giving the arm a "Popeye" appearance.  This can be accompanied by what appears to be significant bleeding but a little blood goes a long way under the right conditions.  Although you'd think a ruptured tendon would almost demand repair, that's not the case here as these very rarely get repaired.  And the Popeye muscle appearance?  It diminishes significantly over time.

Torn Cartilage, SLAP Tear  Much like the meniscus or knee cartilage of the knee, there exists a circular fibrocartilage ring in the shoulder which works much the same way and is subject to some of the same injury patterns.  But, unlike the knee, the shoulder is not a weight bearing joint and similar appearing structures may function in different ways. One example is the origin of the bicep tendon inside the shoulder joint.  When it tears it's what's known as a SLAP lesion and may require arthroscopy to repair or remove it.

Rotator Cuff disease and impingement  This would probably be the most common source of swimming related pain, particularly during the recovery phase of the stroke.  The cuff is made up 4 muscles of the shoulder and functions basically to keep the joint in correct orientation while the stronger muscles like deltoid do the "heavy lifting."  Physical therapy and other conservative measures can be most successful in restoring pain free shoulder function, but they don't do so over night thus cooperation and patience are helpful.

While not an exhaustive list, these are some of the more common shoulder issues and may give you a start on self-diagnosis if your shoulder begins to ache.  An accurate diagnosis is a must if the athlete is to get back to the sport in an expeditious manner.

Dr. Vollmar lecturing Primary Care Physicians

P.Z. Pearce, Director of Ironman Sports Med program in Hawaii

Sunday, April 8, 2012

Tips for Race Day

"The tragedy of life is not that it ends too soon, but that we wait so long to begin it."      W. M. Lewis

Spring is here, and so are the races.  So here are some tips put together by Mark Lorenzoni , 30 year veteran of the local running scene which are applicable to most.  As regular readers know, this blog is slanted to help athletes succeed in racing but to also hopefully succeed in their quest to remain uninjured.  This piece represents that approach.

1.  Whether you're trying to win your age group, or merely trying to win a bet with a friend who said, "You'll never make it to the finish line!," everyone who comes to the starting line is better served if the have a specific goal and a game plan.  Knowing approximately what pace you need to be maintaining for each of the three events makes the race go quicker and with less pain.  Even if you're just trying to finish, you need to have a rough idea of how to get there.

2.  Don't work out over 10%/day in the week leading up to the race.  For example, on Monday in a week where you plan to participate in a sprint triathlon on Saturday in about 1+30, six days hence, you'd want to work out 54 minutes or less. Wednesday is 4 days out, so nothing more than 36 minutes.  Some feel that backing off this much is hard to do, until they find themselves feeling pretty good when they exit T2 on Saturday.

3.  Pick up your race packet the night before...a natural no brainer.  It makes your race day experience that much more stress free when you already have your race number pinned to your shirt and instructions in hand before you hop in bed the night before.

4.  Don't try anything new the week of the race.  This hold true for the night before and those critical and those critical hours and minutes leading up to the start on the actual morning of the event.  Whatever Friday evening meal, amount of Friday night sleep, Saturday shirt, shoes, shorts and socks that have worked best for you over the past 6 months is what you want to duplicate on race morning.

5. Practice your transitions.  This is one of the easiest ways to make up time, and pass people who haven't practiced theirs.  It's not hard to set up a little transition area in your driveway, put on your wet suit if you plan to wear one, and run from the street like you'd exit the water to your little T1, doff your wet suit (with appropriately placed ankle lube, get ready for biking, run your bike to an imaginary mount line...and go.  Do the same for T2.  Not only is it fun, you make an automatic list of the things you need on race day.  (Have I ever gotten to a race without something important, for example bike shoes? Of course.  Learn from my mitakes)

6.  No matter how many times you ask athletes to "go out slow" a great percentage of them succumb to the evil temptations of how "they feel" and end up getting sucked over to the dark side by going to quickly over the first part of the course, particularly the bike.  Your first mile should be the slowest of the entire race.  Accomplish this and I practically guarantee you a great race experience all the way to the finish line.

7.  Above everything else, enjoy the race experience.  So many people have diligently trained all winter for their big day and completing the course is nothing short of fantastic.  So, have fun, and celebrate your amazing feat.

8.  Post-race recovery is sorely abused by type A triathletes.  I takes 7 -10 days to recover from a sprint triathlon, 2-3 weeks for an Olympic distance race, etc. but many folks jump back into their regular training right away.  Big mistake!  So shorten your runs and bikes for a while and back off the pace.  They say that chocolate milk and something to nutritious to eat in the first thirty minutes after the event can kick start your recovery. Ice, foam rollers, and stretching can also be helpful.

Who knows, you might kind of like this sport.  Many do.


Friday, April 6, 2012

The Reason I Have Two Headlights/Meniscus Tears Part 2


Doctors learning how to better care for their triathlete patients.

I'm just leaving Palm Coast, FL after teaching an Orthopedic Update to about 200 Primary Care docs, our front line of medical care.  It's always fun to lecture although it takes a good deal of effort to construct these Power Point Presentations. But, for the most part, these docs are curious, interested, and sponge-like in their thirst for improving their knowledge base.  This makes them better docs....and better able to care for you.  Sounds good to me.

While biking in the moonless pre-dawn hours yesterday, my headlight flaked out.  The even better news was that this was a back road well known for deer, so much so that even the state warns motorists.                                                                                                                     

So, while on the speedy downhill portion of this road my head light just goes black.  Any thoughts on what you might do, especially to avoid potentially meeting Bambi in the dark?  For me it was easy.  Stop the bike, feel under my elbow rest for my back up Blackburn Flea Light that I had charged up off the PC not too long ago, decide high or low beam, and off I went fairly confident I wouldn't meet any creatures of the forest on that particular ride.

The point here that that, in all things biking, or running for that matter, and I'd definitely include racing, you need to be prepared for the unexpected.  Most all of us carry a spare tube, some Allen wrenches, etc. but would we be prepared for a headlight malfunction?  I'm guessing in most instances, no.  But it's a situation easily reversed.

End of the off season/stress related injury.  Ok gang, hibernation is over, and has been over for a while now.  That first race is just around the corner as we've pushed our training up from a few work outs per week to, in some cases, a few work outs per day!  Cross training with volleyball, squash or cross fit is probably done.  One positive side effect is early season weight loss and the ability to be perhaps a little less diet conscious.  This is also a good time to reassess our training load and it's rate of increase.  Your body sees this cumulative effort as a necessary part of the training process consistent with your defined goals of the season, one of which should be to do your best to remain injury-free.  So, using the "ounce of prevention" thought process, if you miss a work out, Joe Friel teaches us that we don't need to try to make it up.  We don't need that little bit of overload that might push us into a stress related injury.  We learn to respect those little signs of plantar faciitis, early Achilles tendinitis, knee pain, etc. and know when we're overloading the machine.  Listen, your body's talking to you.

Meniscus Tears - What to do  (continued from 4/1/2012)  Although the meniscus used to be removed on a regular basis, the medical world ultimately realized that it's of vital significance to the knee.  Symptoms of a tear would include pain, swelling, diminished range of motion, tenderness over the torn meniscus, and occasionally a pop or click when the knee is moved.  The diagnosis would be based on physical exam, x-rays, and commonly an MRI scan.  But understand that just because a tear is seen on MRI that surgery is automatic.  It's not.

The meniscus, or knee cartilage,  serves as a shock absorber as well as aiding in the stability of the joint.  It allow the forces across the joint to be distributed over a wide area. When meniscal tissue is lost, it can, in some cases, lead to an earlier arrival of arthritis than if the knee had never seen trauma.  Sadly, injuries to the meniscus are all too common following a jolt to a knee.  Our gal in last weeks blog, Meniscus Tears 2012, at 50+, will likely undergo removal of the torn portion of her meniscus.  We call this a menisectomy.  I suspect that many readers of this blog are a tad younger and in their situations, a repair of the meniscus would be appropriate if possible. This means that rather than remove the torn portion, the surgeon will use sutures, tacks, etc. to sew the pieces back together.  An adequate blood supply and a stable repair are required for success.   And, the post-operative regimen following a repair involves a much slower mobilization/return to sport than simple tissue removal.

In short, if you have a knee injury with swelling, pain, possible clicking or locking, and the doc says torn meniscus, at least now you are educated to the point that you know what questions to ask as the injury relates to you.  Good luck!

If you have any problems or questions, feel free to let me know.
Image 2, Google images

Tuesday, April 3, 2012

For Those Who Can't Run or are Always Injured

"Man's most valuable sense is a judicious sense of what not to believe." Euripides


There are more tri forums out there than you can shake a stick at. Many opportunities for the give and take of advice, especially when the questioner has some type of physical issue that, more than likely, has been experienced by others in the forum. But, when questions are answered by an anonymous poster, how valuable is the response rendered? Does Captain Underpants really know whether or not I should get a PRP (Platelet Rich Plasma) injection into my Tennis Elbow or is this bogus advice?

A short while back, Jeff Yeager, a level headed participant in the tri forum, posted the information below as one way to allow the body to adapt to the changing stress levels placed on it by triathlon. I have posted the statistics before that in recreational runners, upwards of 50% will have a running related injury this year and it climbs closer to 90% for marathon runners. Here's Jeff's approach (printed with permission) which has worked for many athletes. You might be one of them.


Hawaii 2009 057

From Jeff Yeager:

This is a public service announcement.

I always hear non-runners, some sedentary, some cyclists or swimmers, saying that they can't run because "insert statement here about a bad piece of anatomy".

I think that in 95% of these cases these people have not attempted to adopt a running program in the proper way.
Before I go any further I want to go on record as saying that for people with a serious existing injury or degenerative disease that persistence won't pay off in your case. If you have a specific diagnosis or medical advice, don't follow my suggestions.
We have all heard that contrary to intuition, triathletes experience running injuries as often or more often than runners (here 'runners' means someone that focuses only on the sport of running).

The reason for this is simple. By running every day, runners adapt to the stresses of running far more readily than a triathlete does. Running is all about physical adaptations to the specific stresses of running.

Change your mindset about running and stop considering your running 'limiter' to be your cardiovascular or muscular endurance. First and foremost it's the ability of your bones and connective tissue to endure the impact.
What worked for you when you were 16 years old and joining the track team doesn't work for you later in life when you are probably heavier and have far less growth hormone coursing through your body. And besides this, many high school and college running programs have a 25-50% injury rate each season!

When I returned to triathlon (and running) about 5 years ago I began to experience a string of running injuries one after another. They all occurred before I even exceeded 15 miles per week and affected me nearly continuously for 4 years.
There were shin splints (repeatedly), plantar's fasciitis, aching knees, a serious run of SI joint dysfunction (2 years!), torn calf muscle, finally culminating in a torn plantar's fascia that resulted in a whole season of racing but no run training.

When I began to return to run training once again here's the approach I took:

5 minutes of running on a treadmill 3 days per week. I did this for 3+ months. I then moved to the next phase which was 10 minutes at a time. Phase 3 was adding 5 minutes on the other 2 weekdays between the 10 minute days.
Right now I am 1 year in to my VERY gradual build and I'm doing alternating 2/5 mile runs on weekdays with a Sunday run also. I'm still building and will be for 1-2 more years.

The big breakthrough is that now after a 5 mile run in the morning I feel like I could go for a second run in the afternoon. The next morning when I get out of bed I don't feel any of that leg tenderness that I've been plagued with the next morning for 5 years.

I attribute this to 2 things:

1) allowing my build to be VERY gradual knowing it was all about conditioning the body to the trauma, not for the cardio benefits.

2) running 6 days per week.

In regard to your running you need to change your mindset. You aren't training to be a killer runner next season, but 3-4 seasons from now. Your best friend is being injury free so you can run every day. Even 3 miles per day every day for 3 years will have you racing faster than going from 50 mile weeks with speed work to 3 months injured over and over again.
The body adapts when it receives a stressor that exceeds it's current adaptation level. This is why those extremely long weekend rides are important for Ironman. it's why those long weekend runs are so valuable for marathon.
If you were immune to injury then running 3 days per week with a 20 miler on the weekend would be a great way to train for triathlon, but it's a recipe for injury unless you are starting out as an avid single-sport marathoner already.

So my advice for you is simply this:

1) if you are 'fragile' then take a far longer view of your run training and start with something that seems pointless: 5 minute runs. (or whatever amount you KNOW is easy on your body)

2) Run 6 days per week. Fit this in to your current routine by adding 5 minutes of running either after your bike or after your swim on the days you don't normally run. This extra 5 minutes on off days should be easy because it's only 5 minutes. And doing it after the swim or bike? That's because you are already warmed up and I think that our bodies are a bit like car engines. In a car engine 90% of the wear the engine experiences is during the first few seconds after a cold start. I think that much of the trauma our bodies experience when running is the first mile and that is largely mitigated by never starting a run cold.

3) When it's time to add intensity (perhaps a YEAR in to a daily running regimen?--Remember this is talking to those prone to injury), then I suggest adding the intense running in the same way you added slow running...some ridiculously small amount 5 100 yard stride outs...then eventually becoming 5 minutes of speed/tempo placed in to a regular training run and over the course of many months you will ONLY THEN be ready to do a 'typical' speed workout seen in many training plans.


Put this in the back of your mind as one way to approach this thing we call training. WWED? Or, What Would Euripidies Do?

Sunday, April 1, 2012

Meniscus Tears/Arthroscopy 2012

Otter popping up through abandoned ice fishing hole.

We recently returned home from a week in Northern WI where the lakes were still frozen solid and the ice fishermen out in force.  When I asked a friend if he was into ice fishing, he responded, "I don't ice fish. I love my wife, so that eliminates the most common reason to partake in the activity."

Very cute.
I've chosen meniscus tears this week because they're so common that I almost always have a question in my in box relating to them or to arthroscopy,  If you think about it, we haven't had the slick, out patient surgical skills that we currently practice for all that long.  Even 20 years ago, some people were still performing open (not arthroscopic) menisectomy where an incision of variable size was placed in the knee and the entire meniscus removed with a special knife. The ability for a patient to have two 4mm puncture wounds in their knee (small enough that most of the time they don't require stitches) to fill the joint with fluid, have a complete examination of the inside, and then only the torn portion of the meniscus cut out, should be appreciated as an amazing thing.  Think of how much less trauma is done to the joint in this fashion, how much of a decrease in pain there is, and how quickly people return to their pre operative good health.  I could give you countless examples of patients just like you and me who, a week out from a scope, have returned to 90% of usual daily living.

One of the gals in my morning exercise group, about 50 years old, had me examine her knee last week complaining of pain over the (medial) inside.  Although in young people, a twisting injury is often part of the history, she'd just had the gradual onset pain, worse initially with running, and an inability to straighten her knee fully.

Although swelling is very commonly found in a knee with a problem, thinking that this could be a torn meniscus, she had none.  But, she had exquisite pain right over the joint on the inside of knee with no signs of instability.  Some times you can get a knee like this to click (McMurray test) but I could not.

So, if this had been you in a care giver's office, frequently the next step would be an x-ray.  I know many of you think straight away that an MRI is the next step but often times the diagnosis can be made without the services of the MRI department.  Think of how much money this saves the patient and the system.  Think anywhere between $1000 and $2000 depending on a number of factors.

In her case, she'd already been x-rayed, had endured this pain for months, and again, couldn't straighten her leg.  I felt that she had a meniscus tear and that an MRI was a cost effective step in her care.  The scan turned out to be positive for a tear with out arthritis - good for her - and not much else was found to be abnormal.

I don't know of any non-surgical way to remedy this situation so we talked about scopes, anesthesia options, rehab, etc.  When you or a family member are the patient, the more educated you are about the problem the better able you are to help provide assistance.  So, as might have been said by Don Adams or Barbara Feldon, "Get Smart!"

When you're "Smart" you'll learn that if the major diagnosis for our lady had been age related deterioration of the joint, arthritis, we are no so eager to scope these folks unless they have mechanical signs from an accompanying meniscus tear.  In general, you don't scope arthritis.  For years, we would offer patients a knee arthroscopy to clean up the joint, but we found out repeatedly that we were back to square one pain wise in six months.  Or less.  If you expose yourself to the risks and expenses of surgery, you'd expect improvement to last more than six months.  (This avoidance of arthroscopy would not always be true when considering other joints like the shoulder, a non-weight bearing joint, where a generalized "clean up" can produce dramatic improvement.)

So let's wish our lady all the best at her up coming arthroscopy and that she's back out training before long.

If you have any arthroscopy related problems or questions, let me know.

Images 1 and 2, AAOS