Sunday, June 30, 2013

Honestly, You Need to Respect Your Injury

"I always wanted to be somebody. Now I realize I should have been more specific!"  Lily Tomlin



A Quick Comment on Sleep

Many age group athletes get too little sleep. They fail to allow for the, sometimes considerable, time that training takes out of their day.  Takes out of their lives some would say.  According to South African physician Tim Noakes, if you are working out two hours per day, and sleeping an extra hour per night, you have "lost"  3 hours per day and whatever you would normally do during that time must give way.  But we triathletes rarely do it that way.  Instead of budgeting our time to account for training, we let the other obligations cut into our valuable sleep time, write it off to multi-tasking, "I'm just the busiest gal I know," or some such frivolous rationalization and fail to achieve adequate rest.  By doing so, we diminish human growth hormone production, much needed to repair our tissues from the breakdown that occurs while training.  The moral of the story is that all parts of your day are important: your family, your job, your to-do list including the day's work outs, and right up there as well for optimum performance, your rest.


Respect your injury

Many triathletes are psychologically stronger than they are physically.

 Many athletes focus on training related injures involves solely whether or not they’ll be affected in an upcoming race.  Little thought is given to making injury resolution priority #1.  They've sought help from a friend, an internet forum, or local medical professional.  But in the end, many realize they've invested so much time and energy as part of this sport, there's a good chance they know more about themselves athletically than any physician.  But this is likely not true medically.   It does, however, give them an insight into helping their care giver help them. It's a pretty unique patient-doctor relationship that as a physician I enjoy.

 Brett Sutton, famed coach of Teambb, think Chrissie Wellington, views it this way: "injuries are nothing more than a test of character.  You see quickly how they deal with adversity.  Injuries go but the scars remain in the minds of most." (Sutton's comments leave me wondering if those are positive or negative scars.)

 The take home message here is that we will all be injured at one point or another, some of us frequently, some of us annually, some less.  You know that all of us get a great deal more out of of triathlon than finish line times.  Although you've heard this before, you can't hear it often enough.  Listen to your body.  Is that new knee pain, foot pain, shoulder ache something that you've had in the past and you know will vanish or is it something else?  Many triathletes us are stronger psychologically than physically!  Really.  And if you don't know it, your body certainly does.  (Those of you old enough will recognize the name Gordon Liddy, chief organizer of the White House Plumbers, responsible for the Watergate burglaries during the Nixon administration.  He was noted for "holding his hand over a lighter flame until the flesh burned.")  If we have the potential to do things to ourselves in the name of fitness, we have the potential to undo them in the name of fitness as well.

 Monday is the "most commonly injured" day.  It's not actually. It's just the day that people complain of pain the most. "I don't understand it. I just ran my usual 5 miles this morning."  What they don't see is that it may have taken a couple days for the effects from Saturday's big brick workout to become apparent.  I see it all the time.

 Take  Coach Stacee Seay,  she is a master at achieving a sense of balance between offspring, job, triathlon and just plain enjoying living that many strive for but few of us achieve. You know how when you're talking with one of your tri friends, (or perhaps someone talking to you? Am I getting warm here?) and it becomes obvious that your idle chatter is cutting into their work out time?  And they start to fidget?  And then they fidget a little more?  And if you talk to them too much, "Well, my T1 split at his race was 2:33 but at he next one it was blah, blah..." they go into a full grand mal seizure?  Yeah, I thought you did. It reminds me of one of those Whack-A-Mole games.........

 Stacee doesn't do that, ever. She has this sense of calmness, of control, that everything's going to be OK.  I think this is because she sees triathlon as a part of life, but not life itself.  Like many successful athletes, she's learned to utilize the darkness.  She's plans work outs around work and life instead of the opposite, even if this means getting that morning work out done before heading to the lab, it gets done. Achieving this awareness can be quite valuable. When you're the first one up, you can get in a run... and wave to the deer and the newspaper guy.  Or, get in some time on the trainer, with Phil Liggett and Paul Sherwin distracting you with previous TdF dvds.  My swim group meets at 5:30.  In short, you can get in some quality training and be done when others are just stirring.

Lastly, I had someone tell me once that they'd think twice before hiring some one deeply involved in this sport.  Sure, the old adage about giving  something you want done to the busiest person you know is part of this.   But does the candidate think, plan, drown in triathlon thoughts during their work day to the point that it diminishes their effectiveness....?

But then as I later thought about this comment, or more important here, the commentor, I came to realize he was simply describing himself.

Just one more thing to think about.  Happy training.


Tuesday, June 25, 2013

Statins Possibly Put Triathletes at Risk

Because statins are everywhere, you're going to hear about this soon.  You might as well get an unbiased start on how to interpret what you read and whether it's something you need to learn more about.  Or more importantly, something that indicates you need  change your treatment with regard to this class of drugs.

"They should put Lipitor in the water." Local Virginia internist, 2010

Statins.  Lipitor, Crestor, Mevacor, Zocor, etc. are members of a group of drugs prescribed to those who have elevated serum cholesterol and are unable to lower it to within the normal range thru dietary manipulation and exercise.  It's estimated that between 15 and 20 million of us take this medication on a daily basis.  According to NIH data, more than twice that many would benefit from it's use.  Although proven effective for those with documented cardiovascular disease, there's some debate about it's prophylactic benefit in those of us with high cholesterol but nothing else.  In some settings the drug decreases overall mortality and incidence of stoke so, for the right individual, this can be an important part of therapy.  Whether or not this is indicated for you is a decision between you and your physician.

A recent report on JAMA Internal Medicine stated, "The chances of any musculoskeletal disease diagnosis in those taking statins was significantly higher when compared with non-users (odds ratio 1.19) reported  Ishak Mansi, MD, of the VA North Texas Health Care system..."

So what does this mean?  This is the first study to make an association between this class of drugs and the probability of being diagnosed with some type of dislocation/strain/sprain.  But, this is only one study and the authors are quick to point out that there is some conflicting data and have "called for more research into these findings."  They also correctly note that "all of their results should be confirmed by other studies."

So what do we do?  Well, probably nothing, yet.  First thing, you don't stop a medicine, any medicine in my opinion, without the knowledge of the person who put you on it.  Depending upon the medication, there can be some pretty significant negative effects when stopped suddenly.  Ask your care giver if there needs to be some other option to your taking this and if the answer that you continue the drug makes sense, do so.  Plus, it wouldn't be the first time a study "proves" something that is later disproven, a math error is found, the study group ends up flawed, etc.

As has been noted before, triathletes are "early adopters" and will try, or eliminate, things with only partial proof.  Think compression clothing, kinesio tape, most supplements that tout your ability to "leap tall buildings at a single bound" when taken before your next "A" race, etc.

I wanted to end with a quote about thinking and acting, and found this from Earnest Hemingway - "Before you act, listen.  Before you react, think.Before you spend, earn.  Before you criticize, wait.  Before you pray, forgive.  Before you quit, try."


October hawaii '07 137

Underpants Run, Kailua-Kona, HI 48 hours before IM

Sunday, June 23, 2013

Injections in Orthopedics, Knees, Shoulders. What's Changing.


Professor: If I gave you a dollar and your father gave you a dollar, how much would you have? 

Larry: one dollar. 

Professor: you don't know your arithmetic. 

Larry: you don't know my father.   The Three Stooges



I've talked before about various injections that we as athletes get be they cortisone or something else, like platelet rich plasma (PRP) for swimmer's elbow or hyaluronate for arthritis, etc.   We have painful trigger points injected - the soft tissue - or, infiltration of a bursa when inflammation occurs as  we have bursae (bursas) in many parts of the body.  Infrequently for tendinitis and frequently for arthritis, the doc can warm up the needle.  Occasionally there's a role for joint injections.  In the past, the standard has frequently been to mix some type of steroid agent along with a local anesthetic. No, these are not the anabolic steroids of muscle builders (....or perhaps a pro cyclist or two??), but ones from a different family.  Lidocaine and Marcaine are common choices for the anesthetic and I'll bet that millions of injections have been done this way.  

In recent years however, following the observations of many folks who've had shoulder arthroscopic surgical procedures, a deterioration of the joint lining cartilage has been seen in some who have had a post-op infusion pump with continuous flow of the local anesthetic.  In other words, following surgery, we try our level best to reduce or eliminate pain and the local anesthetics lidocaine and marcaine have helped do this.  But when placed in the joint, we've determined that the cartilage cells respond poorly and it seems best to change our procedures.  The lesson for the reader is that when indicated, have the injection, but lean away from the "cain" inside the joint.  In short, Injections can be recommended for a host of musculoskeletal problems and different types have different roles.


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, while improved initially, is actually made slightly worse over time in some athletes.

 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.  PRP has, so far, had impressive results when used for PF.  However, PRP injections can be multiples of dollars more and not always covered by insurance, something you'd best find out pre-injection.  Achilles Tendinitis is helped by neither, and many practitioners (including this author) are very hesitant to inject either the Achilles or Patellar Tendons - with very good reason.  Complication potential.  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.  The infiltration of the subacromial bursa, the most common injection done in the shoulder, is a good place for the "cains" as it's not a joint and they are excellent as part of a diagnostic work up.  I've had a few myself actually.

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 in the knee, less so in the shoulder.  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, sadly, procedures such as these only help for a short time in a sizable percentage of patients.

 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.  That said, triathletes who head to the doc looking for the quick fix at the end of a needle a few weeks before the "A" race often find themselves disappointed.  

Lastly, Jay Leno offers, "Nineteen percent of doctors say that they'd be able to give their patients a lethal injection. But they also went on to say that the patient would have to be really, really behind on payments."



Images 1,2 Google images

Wednesday, June 19, 2013

Cartilage, Arthroscopy, Microfracture and the Triathlete.

 "Tradin' my time for the pay I get, Livin' on money that I ain't made yet...."

                                                                                                                Five O'Clock World, The Vogues

Hawaii 2010 129

Next time you think that your triathlon successes are a solo effort, maybe you should think a little more carefully and include your support team.



As you might suspect, I get letters like this on a pretty regular basis.  Let's see if we can't help this athlete:

Dr. Post, 
I recently had an MRI that indicated "full thickness chondral loss along the apex and medial facet measuring 0.8cm in dimension -focal severe patellar chondrosis. The initial injury occurred in a hockey game, and I made it substantially worse over a year attempting to cycle and elliptical. Currently simply walking 500 feet causes discomfort. 

My OS gave me orthovisc injections, and sent me to physio to try to strengthen my VMO. There has been no improvement whatsoever. 

I'd like to attempt some type of surgical fix. Would microfracture be a reasonable first step?

                                                                                                                      Tina Triathlete

This is a request from an active athlete who wishes to remain so.  Tina is describing a  problem with the articular or joint lining cartilage.

When the joint lining cartilage begins to break down, arthritis if you will, the owner has a problem.  It doesn't happen overnight and very frequently the owner of the knee is hard pressed to remember a specific accident or incident that lead to the current complaints.  Initially of course, conservative (read non-operative) options are tried including activity modification, NSAIDs, injections of various substances, maybe even physical therapy or bracing depending on the situation.  If these prove unsuccessful, the talk may turn to arthroscopy of the knee, usually performed in the outpatient setting under either general or regional (not local) anesthesia.  Two or three, one quarter inch incisions, so small that suture closure is rarely necessary, is all it takes.

One of the tools available during arthroscopy is known as microfracture. The goal is to get the body to use it's own resources to "heal" this cartilage problem. Although not a cure for arthritis, it can produce a new type of cartilage where there was little to none, in selected patients, and upwards of 80% of patients exhibit a reduction in pain and swelling and improvement in function.  


During microfracture surgery, if the surgeon feels the patient qualifies, a small awl is placed through the arthroscopic holes and a series of small "holes" or punctures are made in the arthritic area about 4mm apart to allow bleeding and the formation of a uniform clot. Slowly, over time the clot matures and patches the damage. Crutches are often used for the first 6 weeks or so but motion is encouraged. Rehab might include Physical Therapy, weights, stretch cords and occasionally a brace. My patients would not be permitted to return to sports for 4-6 months following the procedure, some even longer if they participated in a jumping sport. This would best be determined by one's Orthopedist who knew the exact size and location of the lesion. Most patients continue to slowly improve over the first year post-op, some even the first two years.


A small percentage will fail and they may become "ex-runners" knowing that some day they may need further knee surgery of a greater magnitude. Although there are a host of knee arthritis procedures, this one has given many mid term happiness and a return to athletics.



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.

A fascinating recent development in cartilage repair is called BioCartilage, "designed to provide a reproducible, simple and inexpensive method to augment traditional microfracture procedures.  It is developed from allograft cartilage that has been dehydrated and micronized. BioCartilage contains the extracellular matrix that is native to articular cartilage" made by the Arthrex Corporation.

                                                                                                                                                                          Biocartilage 0 large


This is a relatively new product but the hope is that it produces a more permanent match to one's own articular cartilage.  If it develops a successful track record over the long haul, it could be a real boon to the athletic community.


Images 2, 3 Arthrex Corp

Sunday, June 16, 2013

Testosterone, Should I?

Hitch hiking.  Used to be, you'd see folks hitchhiking all the time.  But as times have changed, and as people have become more concerned about safety, it gets harder and harder to get someone to stop and pick you up, even if you look like Lindsay Vonn.  My older son was hiking in the Sequoias in California last month and had travel all worked out.  Except for one stretch.

His solution, "Easy.  I'll put on an Ohio State shirt."  No, since you've asked, he went to UVA for both undergrad and graduate degrees, "But, heck, everyone knows someone who went to Ohio State, Dad."

Sure enough, after solo summitting Mt. Whitney and exiting the park, he put down his pack, donned the Ohio State shirt, and "Didn't have to wait long at all to get picked up."

Many ways to skin a cat I guess.


Weight Gain and Runners

"Running distance needs to increase annually by 1.4 miles/week in order to compensate for the expected increase in waist circumference between ages 20 and 50.  This means that runners who average 10 miles per week at age 30 should increase their weekly running distance to 24 miles by age 40 if they plan to fit into the tuxedo they bought ten years earlier."  J. Thornton


Testosterone, Clouds on a Cloudy Day

I've been interested in supplements and vitamins for a long time.  Triathletes are smart people.  But they're still people.  And if there's some kind of competitive advantage to be had by a pill or treatment, for athletic or personal gain, they're going to try it.  Heck, triathletes would put colored tape on their body or wear clothes to squeeze them if they thought it would help.  Oh, wait, they already do that.

Enter the supplement industry. Or would it be more accurate to label it the selling of dreams industry.

There are 100's of supplemental products out there each claiming to be able to boost your mitochondrial oxygenation, lose weight fast, or give you greater endurance the last couple miles of a half Ironman.  Why, if it's the next great performance enhancer, is a supplement called Rhodiola, reportedly a "Himalayan root used by the Sherpa people to "adapt to the stress of living and working at high altitudes," on same page with an add telling me how to carve a turkey?

 Or another "serious" advertisement that I am supposed to ponder, to decide whether or not I should seek a certain treatment agent, but it's on the same page with a picture of a young woman and the catch phrase "6 Best Sets of Real Breasts...?"    Why, if these additives work so well, and I have watched believers grind up fifteen - not 3 or 4 - but fifteen,  different pills/liquids/powders in a blender, all reported to make us faster, are we not faster?  Shouldn't at least one or two of these make the user a prime candidate for space flight.  One consumer I roomed with in Hawaii on year was quick to point out that although, "I may not be faster, I am definitely poorer!"

Enter TV and direct to consumer marketing.  "Feeling Low? It might be low t."  Low what?  Where did this come from?  I searched for the term "low t" in two of my standard medical school texts, those 4" thick books you pay so much for, Pathologic Basis of Disease, 8th Ed., as well as my Textbook of Medical Physiology, 12th Ed., and didn't seem to be able to find the term.  Hmm.  And while there's a tremendous amount of information, as well as misinformation, out there that while I don't have time cover it all, let's see if we can't discuss indications for appropriate clinical use of this drug as I understand it in 2013.

Most are already aware that starting around age 30 or so, the bodies normal production of testosterone slowly diminishes over the remainder of a man's life.  Sorry, but that's a fact. Whether or not this is of significance depends on the man since many men in their 70's and older have normal serum testosterone levels, and an important corollary, most men with lower serum levels of testosterone are not symptomatic in any way.  So, one of the key questions to answer here becomes is this normal, age related, lowering of serum testosterone level worthy of replacement therapy?  Is the person symptomatic in some way?  Not the easiest of questions to answer rapidly as you'll see.

A recent study in JAMA Internal Medicine noted the use of testosterone has tripled in the last decade. Men in their 40's are the fastest growing users.  (O'Connor)  Symptoms like low energy levels or diminished libido can have a number of other causes, chief among them, that nasty habit of continuing to have birthdays!  And what's distressing to me. among other things, is that 25% of these patients didn't even get a blood level checked yet they were given the drug.  Would your physician prescribe a blood pressure lowering agent without checking your blood pressure first.  You'd seriously hope not.

So, as is said so often on TV, in ads sponsoring golf, basketball, baseball and other manly activities, how low is the thresh hold for treatment and how many of us really need replacement?  In other low hormonal conditions, once you start, you're on the medication for life.  These relatively healthy men who are starting testosterone at age 40 are potentially going to be exposed for a very long time and we don't know what the risks are.  (Baillargeon)  Also, are there side effects about which we should be concerned?  You bet.  More on that later.

First off, testosterone blood levels can vary widely in the same individual.  They're usually drawn first thing in the morning, as like many bodily processes, serum levels are circadian or variable on a predictable 24 hour cycle.  A host of factors can throw the value off including stress, minor illness, etc.  If you take the drug, sound evidence that benefits accrue has not been forthcoming.  But the complications have been.  Known is the incidence of increased red blood cells according to one Internist I interviewed for this piece.  He explained that as the number goes up, the blood gets thicker and sludges ("A hematocrit of 60," in one of his patients, knowing that over 50 was used for years as definitive evidence for blood doping in cyclists leading to automatic  race expulsion).  That patient was lucky even though he suffered a stroke. "He recovered fully." (Ballew) Also reported are acne, reduced sperm count, fluid retention, gynecomastia or in plain language developing man breasts (sound like fun?) or in those middle aged triathletes, exacerbating pre-existing prostate cancer. 

An often quoted segment of The Colbert Report went something like this, "A man on TV is selling me a miracle cure that will keep me young forever.  It's called Androgel...for treating something called Low T, a pharmaceutical company-recognized condition affecting millions of men with low testosterone, previously known as getting older." 

This ad campaign has been labeled as "a sophisticated effort to define low testosterone as a disease for which the treatment is [testosterone-replacement therapy.] (Braun)

While some may truly suffer from hypogonadism and be candidates for treatment, life long treatment,  I'm not sure that most of the rest of us are.  But, as in the song from Annie, Tomorrow, "Your complete wellness is always one treatment away. (Yuan Sun)


Wednesday, June 12, 2013

Salt, Sodium, Do I Need More?/Sprained Ankles

 "Just once in his life, a man has his time.  And my time is now, I'm coming alive."

                                    Man in Motion, John Parr


Hawaii 2009 258

Sodium, salt, what we know today.

Everybody has an opinion, me included.  This is a subject with more than a little controversy.  The example on one side would be a piece I published here last year from a noted nutritionist and his opinion on sodium loading before races.  The opposite side might be those who rail against the sports drink industry and feel that water in most circumstances is best.

As in many things, perhaps a middle of the road approach works best.  This would be based on what we know in 2013  which, of course, will change, perhaps drastically, depending on what research reveals.

When I first started in triathlon, the dictum was that since we lose salt in sweat, we should make good friends with the salt shaker at meal time.  I can just feel my fellow physicians who care for hypertensive patients cringing.  When examined, the American diet contains multiples of the physiologic daily sodium requirement for sodium.  To be sodium deficient would be a feat indeed.  Oh, and water or sports drinks while competing?  Sports drinks, in my 2013 opinion, are superior in many ways.

Sprained Ankles, Everybody Gets Them

A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle.

The ligaments of the ankle hold the ankle bones and joint in position. They protect the ankle joint from abnormal movements-especially twisting, turning, and rolling of the foot.

A ligament is an elastic structure. Ligaments usually stretch within their limits, and then go back to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers.

How It Happens

Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position.

Mechanism of Injury

If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear. You may lose your balance when your foot is placed unevenly on the ground. You may fall and be unable to stand on that foot. When excessive force is applied to the ankle's soft tissue structures, you may even hear a "pop". Pain and swelling result.

The amount of force determines the grade of the sprain. A mild sprain is a Grade 1. A moderate sprain is a Grade 2. A severe strain is a Grade 3 (see Table below).

  • Grade 1 sprain:

    Slight stretching and some damage to the fibers (fibrils) of the ligament.

  • Grade 2 sprain:

    Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.

  • Grade 3 sprain:

    Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs.




Typical Treatment*

Grade 1

Minimal tenderness and swelling


Microscopic tearing of collagen fibers

Weight bearing as tolerated

No splinting/casting

Isometric exercises

Full range-of-motion and stretching/ strengthening exercises as tolerated

Grade 2

Moderated tenderness and swelling

Decreased range of motion

Possible instability


Complete tears of some but not all collagen fibers in the ligament

Immobilization with air splint

Physical therapy with range-of-motion and stretching/ strengthening exercises

Grade 3

Significant swelling and tenderness



Complete tear/ rupture of ligament


Physical therapy similar to that for grade 2 sprains but over a longer period

Possible surgical reconstruction


See your doctor to diagnose a sprained ankle. He or she may order X-rays to make sure you don't have a broken bone in the ankle or foot. A broken bone can have similar symptoms of pain and swelling.

The injured ligament may feel tender. If there is no broken bone, the doctor may be able to tell you the grade of your ankle sprain based upon the amount of swelling, pain and bruising.

The physical exam may be painful. The doctor may need to move your ankle in various ways to see which ligament has been hurt or torn.

If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also cause damage to the ankle joint surface itself.

The doctor may order an MRI (magnetic resonance imaging) scan if he or she suspects a very severe injury to the ligaments, injury to the joint surface, a small bone chip or other problem. The MRI can make sure the diagnosis is correct. The MRI may be ordered after the period of swelling and bruising resolves.


The amount of pain depends on the amount of stretching and tearing of the ligament. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.


Nonsurgical Treatment

Walking may be difficult because of the swelling and pain. You may need to use crutches if walking causes pain. Usually swelling and pain will last two days to three days. Depending upon the grade of injury, the doctor may tell you to use removable plastic devices such as castboots or air splints.

Most ankle sprains need only a period of protection to heal. The healing process takes about four weeks to six weeks. The doctor may tell you to incorporate motion early in the healing process to prevent stiffness. Motion may also aid in being able to sense position, location, orientation and movement of the ankle (proprioception). Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately. Even if an ankle has a chronic tear, it can still be highly functional because overlying tendons help with stability and motion.

For a Grade 1 sprain, use R.I.C.E (rest, ice, compression and elevation):

  • Rest your ankle by not walking on it.

  • Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily. Combine ice with wrapping to decrease swelling, pain and dysfunction.

  • Compression dressings, bandages or ace-wraps immobilize and support the injured ankle.

  • Elevate your ankle above your heart level for 48 hours.

For a Grade 2 sprain, the RICE guidelines can also be used. Allow more time for healing to occur. The doctor may also use a device to immobilize or splint the ankle.

A Grade 3 sprain can be associated with permanent instability. Surgery is rarely needed. A short leg cast or a cast-brace may be used for two weeks to three weeks.

Rehabilitation is used to help to decrease pain and swelling and to prevent chronic ankle problems. Ultrasound and electrical stimulation may also be used as needed to help with pain and swelling. At first, rehabilitation exercises may involve active range of motion or controlled movements of the ankle joint without resistance. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Lower extremity exercises and endurance activities are added as tolerated. Proprioception training is very important, as poor propriception is a major cause of repeat sprain and an unstable ankle joint. Once you are pain-free, other exercises may be added, such as agility drills. The goal is to increase strength and range of motion as balance improves over time.

All ankle sprains recover through three phases:

  • Phase 1 includes resting, protecting the ankle and reducing the swelling (one week).

  • Phase 2 includes restoring range of motion, strength and flexibility (one week to two weeks).

  • Phase 3 includes gradually returning to activities that do not require turning or twisting the ankle and doing maintenance exercises. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities) such as tennis, basketball or football (weeks to months).


Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to control pain and inflammation.

Long-term outcome

If an ankle sprain is not recognized, and is not treated with the necessary attention and care, chronic problems of pain and instability may result.

Surgical Treatment

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment.

Surgical options include:

  • Arthroscopy 
    A surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint.

  • Reconstruction 
    A surgeon repairs the torn ligament with stitches or suture, or uses other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.


Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.


The best way to prevent ankle sprains is to maintain good strength, muscle balance and flexibility.

  • Warm-up before doing exercises and vigorous activities

  • Pay attention to walking, running or working surfaces

  • Wear good shoes

  • Pay attention to your body's warning signs to slow down when you feel pain or fatigue

Is It Acute or Chronic?

If you have sprained your ankle in the past, you may continue to sprain it if the ligaments did not have time to completely heal. If the sprain happens frequently and pain continues for more than four weeks to six weeks, you may have a chronic ankle sprain. Activities that tend to make an already sprained ankle worse include stepping on uneven surfaces, cutting actions and sports that require rolling or twisting of the foot, such as trail running, basketball, tennis, football and soccer.

Possible complications of ankle sprains and treatment include abnormal proprioception. There may be imbalance and muscle weakness that causes a re-injury. If this happens over and over again, a chronic situation may persist with instability, a sense of the ankle giving way (gross laxity) and chronic pain. This can also happen if you return to work, sports or other activities without letting the ankle heal and become rehabilitated.

Sunday, June 9, 2013

How to Pee On a Moving Bike; Yep, They Do


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

 I like to volunteer at races when I'm not entered.  Those of you who do understand the pleasure you get from helping others, many when they're really in need.  The first time I was a bike catcher, and was handed a pair of disposable plastic surgical gloves for the job, I was completely baffled.  I have three bikes at home including my old mountain bike and sure I get a little grease on me now and again but so what?

"These people do all kinds of things and leave all kinds of stuff on their bikes.  Put 'em on, you'll be glad you did."  

Truer words have not been spoken.

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.
















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.  Man or woman, doesn't matter."  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 in which I was interested 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.


Important Note To Athletes:  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 from Hawaii, I just took all the tri gear and threw it outside on our screened-in back porch to get to it another day.  Well, we all procrastinate sometimes, eh? After about two weeks, my spouse decided to "help" me with cleaning up my stuff.  Nice woman.  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.

Wednesday, June 5, 2013

Limitations, We All Have Them


"A seven nation army couldn't hold me back!"  A competitor, loud enough for all to hear,  at a recent tri just before the gun for his swim wave.  Don't you just love enthusiasm?


Not long ago, in my capacity as Medical Director of Training Bible, I received a question from a woman who had physical pain as a limiter to improving cycling speed. She was very dedicated to triathlon, so much so that despite significant low back pain, in order to continue competing she'd undergone multiple medical evaluations and treatments over the years, even to the point of back surgery. Twice!  And pain was still a problem! Below is a summary of the advice I gave her as many of us find ourselves in a similar boat, particularly as we age and just can't do what we've always done in the past.  As you read this, I think that most any physical problem you experience can be substituted for this person's complaint.

Dear Triathlete,
"You present a particularly difficult, but not uncommon situation: a strong desire to participate limited by physical constraint. A constraint that were it "fixable" it would have been done by now.

So, as Inspector Harry Callahan (Clint Eastwood) famously stated in the movie Magnum Force, "A man's got to know his limitations."  Women, too, of course.  We all have limitations. I've had many patients over the years address, define, and deal with musculoskeletal issues by doing the following: 1) honestly assess your potential given the current restrictions, 2) modify whatever it takes involving your bike, your stroke, etc., 3) then train/race within your personal parameters. We all know folks who used to run marathons or used to do 1/2 Ironman racing, but like you, are now physically limited.

Before paying a couple hundred bucks for a bike fit, we have our patients keep a very specific log for a month or two since they know their body better than any doctor or cycling specialist. They would write down specifically what hurts and make a change, possibly with the local bike shop guy whom they've come to know and trust. Seat up, seat down, bars higher, etc. Keep it for a week and then after your ride, before you even go in the house or take off your cleats, write down exactly what you feel. Same? Different? Better? Worse? WHERE? Now, make another change with the bike guy and do this again. Most notably, just because a friend has a certain aero position doesn't mean you need to. (In fact, with your back, maybe your aero bars belong in the closet.) So frequently what may feel comfortable on a trainer during a bike fit does not 30 minutes down the road. Look at Craig Alexander's time trial position, significantly higher and seemingly less aero than other riders. But, it's comfortable for him and from it he can generate his maximal sustainable power. What works for you may be drastically different from others. Lastly, two ibuprofen before a ride have become a good friend to many (if ok with their doc.*)

The take home here is that we'd all like to perform at a high level indefinitely, but at some point, either through age, injury or just plain bad luck, our plans need to be revised.  Even though some see this as an indication they are less of a person, somehow inferior to those who continue at 100%, I don't buy it.  We are not defined by our 70.1 bike split but by how we treat our fellow man.  I know John Collins, father of Ironman, and he'd say exactly the same thing.  You are not judged by whether or not you can meet some artificial athletic level.  Honest.

Hopefully, this will help you follow the path to success.


*Careful here.  Although many of us use NSAIDs regularly, too regularly some would say, there are issues.

Sunday, June 2, 2013

We Triathletes Never Quit; We Just Don't

"No Mas!"    Roberto Duran


"No mas!' It's one of the classic lines in sports history when Roberto Duran just realized no matter what he tried, he couldn't take the younger, faster Ray Leonard.  I don't know what it's like to get hit with one Sugar Ray Leonard punch let alone a whole fight's worth.  With luck, I'll never find out.  But when training or racing, our sport offers up chance after chance to quit.  To cut a workout short, not make your best effort in the pool, walk off the race course and simply call it a day.

Take a cue from Tim Deboom and Normann Stadler, both previous multi-time winners of the Ironman World Championship.  Unlike some pros, who, if they're not having the day they imagined, will pack it in, saving their energies for another day.  If you were to check the pro results from the 2010 race in Hawaii you'd see that these past champions were completely out of contention, 32nd and 33rd.   They could have easily taken the early bus home and who would have blamed them?  But they didn't, the went every friggin inch of the 140.6 miles and kept the standard which they set. (Never mind Stadler's 2005 meltdown when he had some flat related "challenges"out on the Queen K.)

I bring this up because they say you learn more from races in which you do poorly than those in which you excel.  Personally, I think this is very true. While running the Boston Marathon a number of years ago on an unseasonably hot day, I got to the aid station at about 20 miles, Heartbreak Hill, and either had to sit down or fall down.  So I sat down.  Actually I was almost laying down.  Then I noticed a white school bus parked behind the tables heading to the medical tent near the finish line.  In what would become one of the worst decisions of my athletic career, I got on the bus.  Absolutely no thinking involved!

In the years I've had to rethink that, and pass this mistake on to as many others that I teach as possible, what I needed was to have this question answered before the race, when I was thinking clearly, not through the fog of dehydration.  (Yep, that's what I thought, many of you have been there too.)  I was less than 6 miles from the finish line, I could have walked, strolled really, and still had a reasonable time for the BAA Marathon if I'd just had some rest and fluids at the aid station.  I was a wimp.

Don't be.


Lastly, Cheryl Hart is a fellow consultant to TrainingBible triathlon coaching and a terrific athlete in her own right.  This is from her teaching:

When not to quit...and how.

Next time your mind is telling you that you can't finish the race, do this....

                                 REMEMBER WHY you signed up for this race to begin with.  What do you stand to lose if you don't achieve it?  The goal must be based on one's personal standard of excellence (rather than a comparison with others), self-determined, specific and measurable.  If the answer is firmly fixed in your mind prior to a competition, this will serve as motivational fuel.  This should include a vivid picture of how success will look and feel, including the meaning attached.  

Athletes must practice pushing through the "veil of discomfort" in training sessions to prepare themselves for the mental battles faced during tough competitions.  Each training session should begin with establishing a specific goal that clearly defines success or failure in that particular session.

Lastly, stay fully in the moment.  This means not fast forwarding to the finish (outcome or ego based) but rather focusing on the process, taking one step at a time.  The race seems less daunting if it's broken down into manageable increments.