Tuesday, December 31, 2013

There are some men (and women) for whom the unattainable has a special attraction.

 "There are some men (and women) for whom the unattainable has a special attraction.  Usually they are not experts: their ambitions and fantasies are strong enough to brush aside doubts which more cautious men might have.  Determination and faith are their strongest weapons. At best such men are regarded as eccentric, at worst, mad..." -Walt Unsworth

In my world, they call such people...Triathletes!

Yes, You Can Workout Outside in (Happy New Year) January

This is the time of year when many folks, the non-believers as it were, think we're nuts.  "What, you're going outside to run in this kind of weather, why you must be ______ ."  Fill in the blank with the word you've heard most recently.

We spent the holidays in  Chicago and on Christmas Eve, when our 25 year old son went out for a morning run, at 0 as in z-e-r-o degrees, grandma was after him like flies on flypaper. "How about this wool hat?  Those gloves couldn't be thick enough.  Would you like this scarf? Etc."  And she meant well.  But with a little trial and error, you can still run outdoors providing the footing is safe and visibility OK.  In the car vs runner arena, the car still wins.

It's been said that you heat up 10-15 degrees once you get going so that's in your corner and a friend tells me "There are no bad runs, only bad gear."  Many of us have other issues like Raynauds Syndrome but the piece I did a few weeks ago on winter running should help.  I didn't mention that men can get frostbite of their private parts if they don't make allowances for it with their gear.  Take it from the voice of experience, "It hurts big time." Avoidance is best.

But if you still have questions, head back to your local running shoe specialty shop.  Probably not your generic sporting goods store.  But you don't buy your running shoes at a sporting goods store anyway.  Most likely the sales team is made up of runners - who've had their outdoor exercise for the day already - and would be only too happy to discuss cold hands and feet ,wool socks, mittens, and the like.  It's runners talking about running.  Doing the thing they like second best.

So, from the Post family to yours, Happy New Year, happy and successful training, and here's to a (hopefully) injury free 2014.


Sunday, December 29, 2013

Chest Pain? Cardiac Symptoms? Don't Ignore 'Em, Even If You're Young.

"The great contribution we can make is to prepare the oncoming generations to think for themselves."  Charles Mayo, MD, Mayo Clinic


I spent the day in Rochester, MN at the Mayo Clinic recently and was impressed at every corner.

 "The heart is the first feature of working minds."

                                                                                              Frank Lloyd Wright

We see frequent headlines noting the very premature death of young athletes with pathologic cardiac conditions, the so-called enlarged heart also known as hypertrophic or dilated cardiomyopathy. It's been proposed that athletes participating in multiple endurance events like iron distance racing or a high number of marathons induce subtle changes, which, over time, can lead to significant changes in cardiac function. Negative changes!

Sunday, December 22, 2013

Torn Meniscus, A Very Common Knee Injury


                                                              The bikes are set, the race in 12 hours.

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 25 years ago, some surgeons 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 removed, 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


Thursday, December 19, 2013

Preparing For Winter Running

"But it's a five o'clock world when the whistle blows, no one owns a piece of my time."                                              The Vogues

 Thinking about going for a run after work?  Me too.  Many of the posts on this blog are pointed toward safety.  Visible clothing and possibly a strobe or reflective vest in these shortened daylight hours, being especially prepared if you have Raynaud's, etc.  On 12/18/2011 I did a piece titled "Frostbite Avoidance, Dressing for Winter Training" which serves as a good base for this topic if you haven't read it yet.

Make sure you can be seen in the dark and areas of poor visibility.  I live in a college town and remark on an almost weekly basis that the students ride bikes in low light or no light conditions with no lights, no reflectors and dark clothing making it an incredible challenge to just see them.

    1. Prior to your run, practice dynamic not static stretching techniques like light skips, bounding, high knees, butt kicks and back pedals.  Save the static stretch for after you've completed your run.

Note importance of core exercises (and sledding) in the snow.

  1. Dress properly....not too much and not too little.  Your body will warm up 10 - 15 degrees above the air temperature.  Embrace, don't fight whatever weather conditions you face. It was 20 degrees, in the dark, when we started our work out this morning with 44 folks, and shedding clothing became the rule of the day.

  2. Deliberately start with a very slow jog or fast walk for your first half mile and always make your first mile the slowest of your run.  Your last half mile should also be run at a slower pace as this helps with your post run recovery.

  3. Keep your stride length short and remember the suggested pacing of 30 Rt. foot strikes per 20 seconds (or 22/15 secs.)

  4. Maintain a "conversational pace," aerobic heart rate.  If you can hear yourself breathing, you're probably running too fast.

  5. Follow your RPE, rate of perceived exertion by maintaining the same effort, not the same pace, through out the varying terrain of your work out.  Obviously this is particularly important running up hill.

  6. You longest run of the week should not be greater than the sum of the other runs.  

  7. Take it easy on the down hills, shorter stride length is the key.

  8. Say out of the "gutter" (side of the road) by trying to maintain balanced stride lengths.

  9. Try to get something nutritional into your system within 20-30 minutes of completing your run as recommended by Triathlete Magazine author Matt Fitzgerald in his book Racing Weight.  It could be a banana, Clif-bar type product and a sports energy drink or chocolate milk.  

  10. Make sure you record the stats of the run in your journal including what works and what's not working.

  11. Drink at least 60 ounces of hydrating fluids/ day....sodas don't count.

  12. Make sit ups and push ups, which work on core strength, a part of your daily routine and use Pilates and Yoga as your "cross training."

  13. Get adequate sleep - I know this is hard for most! The more you exercise the more rest you will need.

  14. Listen to your body's communication signals. Feeling fatigued?  Then back off.  Have a new ache or pain (knee, shin, hip, ankle, Achilles?) Then talk it out with your coach ASAP.  

But when you're heading out for that five o'clock run remember that upon hearing Joe Jacobi of the Washington Redskins say: "I'd run over my own mother to win the Super Bowl," Matt Millen of the Raiders said, "To win the Super Bowl, I'd run over Joe's mom, too."

Some say that winter running is the best there is.  If you follow these simple rules, I'm sure you'll agree.


 Thanks to Mark Lorenzoni, author of the above, and his desire to "spread the word." Thanks to NIkki of SEAL Team PT for photo #2.

Saturday, December 14, 2013

Ankle Fractures (Broken Ankle) Part 3, Serious Injuries, Outcomes

 This is the third and final portion of a blog series on ankle fractures.  It covers the most complex of injuries.  If your situation is a little less complicated, feel free to refer back to yesterday or Thursday posts which led up to this one.  If you have any questions feel free to e-mail me.

Treatment: Trimalleolar Fractures

"Tri" means three. Trimalleolar fractures means that all three malleoli of the ankle are broken. These are unstable injuries and they can be associated with a dislocation.


(Left) X-ray of trimalleolar ankle fracture. (Right) Surgical repair.


 Nonsurgical Treatment

These injuries are considered unstable and surgery is usually recommended.

As with bimalleolar ankle fractures, nonsurgical treatment might be considered if you have significant health problems, where the risk of surgery may be too great, or if you usually do not walk.

Nonsurgical treatment is similar to bimalleolar fractures, as described above.

Surgical Treatment

Each fracture can be treated with the same surgical techniques as written above for each individual fracture.

Treatment: Syndesmotic Injury

The syndesmosis joint is located between the tibia and fibula, and is held together by ligaments. A syndesmotic injury may be just to the ligament -- this is also known as high ankle sprain. Depending on how unstable the ankle is, these injuries can be treated without surgery. However, these sprains take longer to heal than the normal ankle sprain.

In many cases, a syndesmotic injury includes both a ligament sprain and one or more fractures. These are unstable injuries and they do very poorly without surgical treatment.

Your physician may do a stress test x-ray to see whether the syndesmosis is injured.


(Left) X-ray of syndesmotic injury with lateral malleolus fracture. Note the space between the tibia and fibula. (Right) Surgical repair.




Because there is such a wide range of injuries, there is also a wide range of how people heal after their injury.

It takes at least 6 weeks for the broken bones to heal. It may take longer for the involved ligaments and tendons to heal.

As mentioned above, your doctor will most likely monitor the bone healing with repeated x-rays. This is typically done more often during the first 6 weeks if surgery is not chosen.

Although most people return to normal daily activities, except for sports, within 3 to 4 months, studies have shown that people can still be recovering up to 2 years after their ankle fractures. It may take several months for you to stop limping while you walk, and before you can return to sports at your previous competitive level. Most people return to driving within 9 to 12 weeks from the time they were injured.


Rehabilitation is very important regardless of how an ankle fracture is treated.

When your physician allows you to start moving your ankle, physical therapy and home exercise programs are very important. Doing your exercises regularly is key.

Eventually, you will also start doing strengthening exercises. It may take several months for the muscles around your ankle to get strong enough for you to walk without a limp and to return to your regular activities.

Again, exercises only make a difference if you actually do them.


Your specific fracture determines when you can start putting weight on your ankle. Your physician will allow you to start putting weight on your ankle when he or she feels your injury is stable enough to do so.

It is very important to not put weight on your ankle until your physician says you can. If you put weight on the injured ankle too early, the fracture fragments may move or your surgery may fail and you may have to start over.


It is very common to have several different kinds of things to wear on the injured ankle, depending on the injury.

Initially, most ankle fractures are placed in a splint to protect your ankle and allow for the swelling to go down. After that, you may be put into a cast or removable brace.

Even after the fracture has healed, your physician may recommend wearing an ankle brace for several months while you are doing sporting activities.


People who smoke, have diabetes, or are elderly are at a higher risk for complications after surgery, including problems with wound healing. This is because it may take longer for their bones to heal.

Nonsurgical Treatment

Without surgery, there is a risk that the fracture will move out of place before it heals. This is why it is important to follow up with your physician as scheduled.

If the fracture fragments do move out of place and the bones heal in that position, it is called a "malunion." Treatment for this is determined by how far out of place the bones are and how the stability of the ankle joint is affected.

If a malunion does occur or if your ankle becomes unstable after it heals, this can eventually lead to arthritis in your ankle.

Surgical Treatment

General surgical risks include:

  • Infection

  • Bleeding

  • Pain

  • Blood clots in your leg

  • Damage to blood vessels, tendons, or nerves

Risks from the surgical treatment of ankle fractures include

  • Difficulty with bone healing

  • Arthritis

  • Pain from the plates and screws that are used to fix fracture. Some patients choose to have them removed several months after their fracture heals

What to Discuss With Your Orthopaedic Surgeon:

  • When will I be able to start putting weight on my leg?

  • How long will I be off of work?

  • Do I have any specific risks for not doing well?

  • If I have to have surgery, what are the risks?

  • Do I have weak bone?

Friday, December 13, 2013

Ankle Fractures (Broken Ankle) Part 2, Specific Fractures

My first trip to Kona was supposed to be with local star athlete Eddie Pierce, but Eddie broke his ankle and needed surgery 3 months before the race.  In a move that wouldn't happen today, I brought his race entry to Kona and when someone at the hotel pool asked,"Anybody know how you can get into this race?"  I answered that I had an entry and that all you needed was to reimburse Eddie his $75 entry fee.  The guy did.  And if you look at that years's race results, you see Eddie Pierce, Charlottesville, VA...but Eddie's never done an Iron distance race!


Yesterday in Part One we discussed the general anatomy and mechanism of injury to the ankle.  Today we cover three of the the more common presentations.  Remember, although we see ferocious hits in the NFL on TV, most of these fractures are a solo accomplishment.

Treatment: Lateral Malleolus Fracture

A lateral malleolus fracture is a fracture of the fibula.

There are different levels at which that the fibula can be fractured. The level of the fracture may direct the treatment.


Different levels of lateral malleolus fractures

Reproduced with permission from Michelson JD: Ankle Fractures Resulting From Rotational Injuries J Am Acad Ortho Surg 2003;11:403-412.


Nonsurgical Treatment

You may not require surgery if your ankle is stable, meaning the broken bone is not out of place or just barely out of place. A stress x-ray may be done to see if the ankle is stable. The type of treatment required may also be based on where the bone is broken.

Several different methods are used for protecting the fracture while it heals. ranging from a high-top tennis shoe to a short leg cast. Some physicians let patients put weight on their leg right away, while others have them wait for 6 weeks.

You will see your physician regularly to repeat your ankle x-rays to make sure the fragments of your fracture have not moved out of place during the healing process.

Surgical Treatment

If the fracture is out of place or your ankle is unstable, your fracture may be treated with surgery. During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment. They are held together with special screws and metal plates attached to the outer surface of the bone. In some cases, a screw or rod inside the bone may be used to keep the bone fragments together while they heal.

Treatment: Medial Malleolus Fracture

A medial malleolus fracture is a break in the tibia, at the inside of the lower leg. Fractures can occur at different levels of the medial malleolus.

Medial malleolar fractures often occur with a fracture of the fibula (lateral malleolus), a fracture of the back of the tibia (posterior malleolus), or with an injury to the ankle ligaments.

Nonsurgical Treatment

If the fracture is not out of place or is a very low fracture with very small pieces, it can be treated without surgery.

A stress x-ray may be done to see if the fracture and ankle are stable.

The fracture may be treated with a short leg cast or a removable brace. Usually, you need to avoid putting weight on your leg for approximately 6 weeks.

You will need to see your physician regularly for repeat x-rays to make sure the fracture does not change in position.

Surgical Treatment


(Left) X-ray of a medial malleolus fracture. (Right) Surgical repair of a medial malleolus fracture with a plate and screws.


If the fracture is out of place or the ankle is unstable, surgery may be recommended.


In some cases, surgery may be considered even if the fracture is not out of place. This is done to reduce the risk of the fracture not healing (called a nonunion), and to allow you to start moving the ankle earlier.

A medial malleolus fracture can include impaction or indenting of the ankle joint. Impaction occurs when a force is so great it drives the end of one bone into another one. Repairing an impacted fracture may require bone grafting. This graft acts as a scaffolding for new bone to grow on, and may lower any later risk of developing arthritis.

Depending on the fracture, the bone fragments may be fixed using screws, a plate and screws, or different wiring techniques.

Treatment: Posterior Malleolus Fracture

A posterior malleolus fracture is a fracture of the back of the tibia at the level of the ankle joint.

In most cases of posterior malleolus fracture, the lateral malleolus (fibula) is also broken. This is because it shares ligament attachments with the posterior malleolus. There can also be a fracture of the medial malleolus.

Depending on how large the broken piece is, the back of the ankle may be unstable. Some studies have shown that if the piece is bigger than 25% of the ankle joint, the ankle becomes unstable and should be treated with surgery.

It is important for a posterior malleolus fracture to be diagnosed and treated properly because of the risk for developing arthritis. The back of the tibia where the bone breaks is covered with cartilage. Cartilage is the smooth surface that lines a joint. If the broken piece of bone is larger than about 25% of your ankle, and is out of place more than a couple of millimeters, the cartilage surface will not heal properly and the surface of the joint will not be smooth. This uneven surface typically leads to increased and uneven pressure on the joint surface, which leads to cartilage damage and the development of arthritis.

Nonsurgical Treatment

If the fracture is not out place and the ankle is stable, it can be treated without surgery.

Treatment may be with a short leg cast or a removable brace. Patients are typically advised not to put any weight on the ankle for 6 weeks.

Surgical Treatment

If the fracture is out of place or if the ankle is unstable, surgery may be offered.

Different surgical options are available for treating posterior malleolar fractures. One option is to have screws placed from the front of the ankle to the back, or vice versa. Another option is to have a plate and screws placed along the back of the shin bone.

Thursday, December 12, 2013

Ankle Fractures (Broken Ankle) Part 1

 "But there are men (and women) for whom the unattainable has a special attraction.  Usually they are not experts: their ambitions and fantasies are strong to brush aside the doubts which more cautious men might have.  Determination and faith are their strongest weapons.  At best such men are regarded as eccentric; at worst mad...  Three things they had in common: faith in themselves, great determination, and endurance."

                                                                                                           Walt Unsworth, Everest

"In my world, we call such men and women, Ironman."

                                                                                                           John Post, MD

Hawaii 2010 035

Ankle Fractures (Broken Ankle)

A broken ankle is also known as an ankle "fracture." This means that one or more of the bones that make up the ankle joint are broken.

A fractured ankle can range from a simple break in one bone, which may not stop you from walking, to several fractures, which forces your ankle out of place and may require that you not put weight on it for a few months.

Simply put, the more bones that are broken, the more unstable the ankle becomes. There may be ligaments damaged as well. The ligaments of the ankle hold the ankle bones and joint in position.

Broken ankles affect people of all ages. During the past 30 to 40 years, doctors have noted an increase in the number and severity of broken ankles, due in part to an active, older population of "baby boomers."


Three bones make up the ankle joint:

  • Tibia - shinbone

  • Fibula - smaller bone of the lower leg

  • Talus - a small bone that sits between the heel bone (calcaneus) and the tibia and fibula


Anatomy of the ankle

Reproduced and adapted with permission from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003.


The tibia and fibula have specific parts that make up the ankle:

  • Medial malleolus - inside part of the tibia

  • Posterior malleolus - back part of the tibia

  • Lateral malleolus - end of the fibula

Doctors classify ankle fractures according to the area of bone that is broken. For example, a fracture at the end of the fibula is called a lateral malleolus fracture, or if both the tibia and fibula are broken, it is called a bimalleolar fracture.

Two joints are involved in ankle fractures:

  • Ankle joint - where the tibia, fibula, and talus meet

  • Syndesmosis joint - the joint between the tibia and fibula, which is held together by ligaments

Multiple ligaments help make the ankle joint stable.


  • Twisting or rotating your ankle

  • Rolling your ankle

  • Tripping or falling

  • Impact during a car accident


Because a severe ankle sprain can feel the same as a broken ankle, every ankle injury should be evaluated by a physician.

Common symptoms for a broken ankle include:

  • Immediate and severe pain

  • Swelling

  • Bruising

  • Tender to touch

  • Cannot put any weight on the injured foot

  • Deformity ("out of place"), particularly if the ankle joint is dislocated as well

Doctor Examination

Medical History and Physical Examination

After discussing your medical history, symptoms, and how the injury occurred, your doctor will do a careful examination of your ankle, foot, and lower leg.

Imaging Tests

If your doctor suspects an ankle fracture, he or she will order additional tests to provide more information about your injury.

X-rays. X-rays are the most common and widely available diagnostic imaging technique. X-rays can show if the bone is broken and whether there is displacement (the gap between broken bones). They can also show how many pieces of broken bone there are. X-rays may be taken of the leg, ankle, and foot to make sure nothing else is injured.

Stress test. Depending on the type of ankle fracture, the doctor may put pressure on the ankle and take a special x-ray, called a stress test. This x-ray is done to see if certain ankle fractures require surgery.

Computed tomography (CT) scan. This type of scan can create a cross-section image of the ankle and is sometimes done to further evaluate the ankle injury. It is especially useful when the fracture extends into the ankle joint.

Magnetic resonance imaging (MRI) scan. These tests provide high resolution images of both bones and soft tissues, like ligaments. For some ankle fractures, an MRI scan may be done to evaluate the ankle ligaments.

Tuesday, December 10, 2013

EPO Discovered in Triathlete's Refrigerator


Triathlon and Suspected Drug Use


Today is a special day.  “The Armstrong Lie,” a documentary by Alex Gibney, opens in local theaters tonight.   Peter Keough of the Boston Globe reports that it “was supposed to be an uplifting film about redemption and perseverance and inspirational victory, chronicling Lance Armstrong’s attempted comeback in the 2009 Tour de France in search of his eighth victory, and vindication from the charges of doping that had hounded his career.

But it was not to be. Just as the film, then titled “The Road Back,” neared completion, Armstrong’s decade of denial collapsed. No longer could he indignantly insist that he never abused prohibited performance-enhancing drugs and blood transfusions to accomplish his “miraculous” triumphs. So a new, darker, sadder story emerged, and a different film, with the title “The Armstrong Lie.”

 I say special day because coincidentally I received an email recently which I'd like to share.  I'll be changing enough of the details to obfuscate those involved.  “A week or so ago, my son was cat sitting for a friend and her husband.  They are both very involved in triathlon at all levels from sprint to Ironman as well as doing some coaching on the side.  Okay, enough background.  Could be anybody, right?  So my son is in their house to feed the cats.  They keep the canned cat food in the frig.  He opened the frig and what is next to the cat food?  A case of EPO.  Yep, Chinese made EPO. “

 Now what?  What do we do now?  What would you do?

Well, I consulted USADA’s Amy Eichner, Phd., Special Advisor on Drugs and Supplements, and she tells me that the EPO could be reported through the Play Clean Tip center http://www.usada.org/playclean and one can remain anonymous if desired.  Or, the info can be shared with the USADA legal director.  Dr. Eichner goes out of the way to say “Thank you for protecting the rights of clean athletes."

We as triathlon supporters can be confused as to what’s a legal drug and what’s not.  I tried to share something with the Ironman audience a couple weeks ago and was basically shot out of the water from reader comments!  They mean well.  They're nice folks just like you and me, but because of some misconceptions on their part, I got comments like... well, let's ask you the same question and see how you reply.  Ready?

Here's the scenario.  Your buddy has knee pain, has failed all the conservative options (activity modification, weight loss, NSAIDs, home exercise program, Physical Therapy, etc.) so he gets a cortisone injection in his mildly arthritic knee.  He races the following weekend.  Uh oh!  I smell trouble ahead.  From a tri point of view, is there a problem here?

Choose one:

a)  the guy's a doper, he should be disqualified

b)  flagrant rules violation, take away his USAT card

c)  if he planned ahead, got a Theraputic Use Exemption from USADA, he's OK

d)  no big deal, it's well within the rules


If you chose d), you're correct.  Surprised?  So should the people who accused me of "endorsing this kind of behavior," and even worse.  One commenter posted " Dr. Post, are you openly encouraging doping in sport?" (Ow! That one really stung.)


Hawaii 2009 222


There are a lot of misconceptions out there by athletes who mean well but may be slightly misinformed.  Let’s look at an entirely legal and appropriate use of the drug in question, cortisone - yes it's a steroid - but one that when used within the rules is not considered performance enhancing.

 Some athletes equate pain with training.  Although we’re surrounded by adages like “no pain, no gain” or “learn to be comfortable being uncomfortable,” we’ve long ago discerned the difference between training discomfort and physical pain.  We’ve also learned that there isn’t a quick fix, a shot or something, for every ache or distress.  When we’re in pain, our bodies are trying to tell us something. But for some tri related injuries an injection can be just what the doctor ordered. 

 Take Dean, a local 54 year old athlete who’s stronger and swifter than most, but alas, he has a spot of arthritis in his left knee.  Oh yeah, and he’s "allergic" to needles!  So at one recent orthopedic visit, his doctor asked him to think about cortisone. “Please tell me I’ll look just like Arnold after the shot, doc.”

 Perhaps he needs to understand a little more about cortisone, or corticosteroids, as they’re known in the trade.  These are actually natural hormones produced by the adrenal glands found near the kidneys that work in a variety of ways in your body including suppressing inflammation and the immune system.  This class of drugs is quite effective in reducing the inflammation caused by arthritis, joint pain, swollen bursae or tendon sheaths in the case of bursitis or tendonitis.  In other disease processes like Lupus or Rheumatoid Arthritis, the immune system actually attacks itself leading to damaged connective tissue and organs.  Cortisone given here helps decrease the activity of the immune system but beware, it also diminishes the body’s normal immune response which could increase your risk for infection. Unlike the anabolic steroids that body builders have been said to use, they won’t turn you into Adonis. (But, hey, you’re a triathlete, Adonis has nothing on you.)

 So Dean has been using a nonsteroidal anti-inflammatory drug, an NSAID, but just hasn’t gotten the level of relief desired.  He knows that for many forms of arthritis, a low dose of oral corticosteroid is prescribed.  But he also knows that for swollen joints, tendon problems or bursitis (inflammation of a tiny sac found between a bone, tendon, muscle or skin that permits these parts to glide smoothly) the corticosteroid is injected directly into the joint or bursa. “Yikes!”


 Meanwhile, back to Dean, nervous and about to meet the business end of a 23 guage needle.  But his physician, knowing Dean’s “allergy” has, after cleansing and prepping the injection site, sprayed it with ethyl chloride, that freezy stuff that numbs the skin.  And just like that, it’s over. “That’s it?  That’s all there is to it?” he exclaims.  “Heck, my transitions should be so fast.”

 Let’s get technical for a second.  The drugs that are injected into the joint, methylprednisolone as one example, are corticosteroids and belong to the glucocorticoid family.  Glucocorticoids are produced in your adrenal gland and have a number of functions in the body.  Some glucocorticoids are on the 2013 WADA list of banned substances. T he paragraph addressing that states:


                  All glucocorticosteroids are prohibited when administered by oral, intravenous,

                  intramuscular or rectal routes.

 When injected into the knee, an intra-articular route, not on the above list, the rate of absorption is slow enough that it’s not listed.  Never has been to my knowledge.  If one refers to paragraph S9 of the USADA Athlete Guide to the WADA 2013 Prohibited List* for verification, you’ll note again the concern for other routes of administration and the in completion/out of competition guidelines.  Again, when injected into a joint, this agent is not on the banned substance list either in or out of competition.

 So dear athlete friends, at least in this instance you know the difference between a legal use of drugs in joint injections, and the illegal use of drugs like EPO in all circumstances.  And the decision of what to do with the information you learn about the conduct of others using illegal measures is entirely up to you.


Wednesday, December 4, 2013

Thumb Arthritis? Hard to Hold Those Handlebars?

"The best laid plans of mice and men of-times go astray."

                                                 Robert Burns*


Although we may spend weeks, months or years even, planning for a single race, we cannot control everything.  Even the most complete preparation is insufficient.  Some time back I entered a sprint tri nearby really wanting to do well.  I was possibly the best prepared for a race I'd been in recent memory.  OK, body marking - check, gear ready - check, warm up swim complete - check.  Then out of the heavens, came an enormous bolt of lightning on the other side of the bay!  "Everybody to your cars," cracked the loud speaker system.  Now you're looking over a fully prepared transition area being soaked, drenched, by pounding rain, more lightning, more rain, and after 2 hours the race was cancelled.  So much for having a good race secondary to excellent planning.  It happens.



Arthritis of the Thumb

I can not tell you how frequently in the office an athlete, female more likely than male, complains of thumb pain with little or no trauma.  The triathlete notes difficulty with their hand position on the bike because of it.  This article is meant to shed some light on this pain.

Arthritis is a condition that irritates or destroys a joint. Although there are several types of arthritis, the one that most often affects the joint at the base of the thumb (the basal joint) is osteoarthritis (degenerative or "wear-and-tear" arthritis).


Smooth cartilage covers the ends of the bones. It enables the bones to glide easily in the joint. Without it, bones rub against each other, causing friction and damage to the bones and the joint. Osteoarthritis occurs when the cartilage begins to wear away.


The joint at the base of the thumb, near the wrist and at the fleshy part of the thumb, enables the thumb to swivel, pivot, and pinch so that you can grip things in your hand.

Arthritis of the base of the thumb is more common in women than in men, and usually occurs after 40 years of age. Prior fractures or other injuries to the joint may increase the likelihood of developing this condition.


  • Pain with activities that involve gripping or pinching, such as turning a key, opening a door, or snapping your fingers.

  • Swelling and tenderness at the base of the thumb.

  • An aching discomfort after prolonged use.

  • Loss of strength in gripping or pinching activities.

  • An enlarged, "out-of-joint" appearance.

  • Development of a bony prominence or bump over the joint.

  • Limited motion.


Your physician will ask you about your symptoms, any prior injury, pain patterns, or activities that aggravate the condition. The physical examination may show tenderness or swelling at the base of the thumb.

One of the tests used during the examination involves holding the joint firmly while moving the thumb. If pain or a gritty feeling results, or if a grinding sound (crepitus) can be heard, the bones are rubbing directly against each other.

An X-ray may show deterioration of the joint as well as any bone spurs or calcium deposits that have developed.

Many people with arthritis at the base of the thumb also have symptoms of carpal tunnel syndrome, so your physician may check for that as well.


Nonsurgical Treatment

In its early stages, arthritis at the base of the thumb will respond to nonsurgical treatment.

  • Ice the joint for five to fifteen minutes several times a day

  • Take an anti-inflammatory medication such as aspirin or ibuprofen to help reduce inflammation and swelling

  • A supportive splint to limit the movement of the thumb, and allow the joint to rest and heal. The splint may protect both the wrist and the thumb. It may be worn overnight or intermittently during the day.

Because arthritis is a progressive, degenerative disease, the condition may worsen over time. The next phase in treatment involves a steroid solution injection into the joint. This will usually provide relief for several months. However, these injections cannot be repeated indefinitely.

Surgical Treatment

When nonsurgical treatment is no longer effective, surgery is an option. The operation can be performed on an outpatient basis, and several different procedures can be used.

One option involves fusing the bones of the joint together. This, however, will limit movement.

Another option is to remove part of the joint and reconstruct it using either a tendon graft or an artificial substance.

You and your physician will discuss the options and select the one that is best for you.


After surgery, you will have to wear a cast for several weeks. A rehabilitation program, often involving a physical therapist, helps you regain movement and strength in the hand. You may feel some discomfort during the initial stages of the rehabilitation program, but this will diminish over time. Full recovery from surgery takes several months. Most patients are able to resume normal activities and are quite satisfied with the results.

*Burns original quote is "But Mousie, thou are no thy-lane, 
In proving foresight may be vain: 
The best laid schemes o' Mice an' Men, 
Gang aft agley."

Where no thy-lane means not alone and Gang aft agley means often go awry.

Image #1, Google images, Dr. Frank Lipman

Monday, December 2, 2013

"Meth-Like Chemical Found in Sports Powder" USA Today

 "I got something to say!"          Def Leppard



Yep, that headline got my attention, too!  It seems that, "A popular sports supplement widely sold in the USA and other countries is secretly spiked with a chemical similar to methamphetamine, according to new tests by scientists in the USA and Korea."  (USA Today, October 13, 2013) Craze is the pre-workout powder in question in the article but the author also notes, "The U.S. researchers also said they found the same methamphetamine-like chemical in another supplement, Detonate, which is sold as an all-natural weight-loss pill by another company."  

Don't get me started.  Craze is touted by the manufacturer to give "unrelenting energy and focus."

 Reportedly, It can be used to:

a) recover from injuries

b) reduce inflammation in the brain from concussions

c) heal sprains or torn ligaments faster

d) speed up the metabolism

e) promote flexible joints,

f) help build a healthier heart

g) and relieve arthritis.  

Wow, all that in one product and it's not on the mandatory list of The President's Council on Physical Fitness?  How come?

If it sounds too good to be true, it probably is

Ring any bells here?  I did a piece on Deer Antler Spray that despite attestations from innumerable high level athletes as a source of IGF-1, insulin-like growth factor, which according to Wikipedia "plays an important role in childhood growth and continues to have anabolic effects in adults." However, in this setting, it's of doubtful benefit.  In fact Ethan Cohen, assistant professor in the Department of Endocrinology and Metabolism at the University of Rochester stated, "I’m 99% sure that eating deer antler to induce muscle growth won’t work."  This is a good read from Business Insider on the fallacy of deer antler substances and is applicable to the decision making process of the triathlete.  http://www.businessinsider.com/what-is-deer-antler-spray-2013-5#ixzz2la3H2wqk

Let's see. What will we tell triathletes this one does?

Deer antler spray sounds like a cure-all, but the scientific backing is flimsy at best.   Most of the product's medical benefits are based on testimonials from self-interested marketers

Ryan Biggs said:

It hasn't been studied, so maybe it does work. But consuming IGF-1 doesn't necessarily mean your body will have more IGF-1 to use anymore than eating hair will give your body more hair. Testimonials about individual experiences are simply not useful - this is the most basic and important idea in science. We are all subject to cognitive biases. The scientific method was developed to control for our cognitive biases. The plural of 'anecdote' is not 'data'. The placebo effect is real, but knowing it is real doesn't make you exempt from it. The best we can say is that these supplements seem to show some promise but more research is needed.

And back to the whole point of this piece, as desperately as athletes want a competitive edge, they're left to ponder the legitimacy of products that.... skeptical scientists all might describe in the same five words: This stuff is beyond real.  We triathletes, the author included, are a hopeful lot.  They plan, scheme, work very hard, and even dream about getting faster.  As Blondie sang in 1979, Dream, dream even for a little while."  The pages of our trade publications are choked with products which promote their consumption will lead to a "strong body, being Superfast, free speed, faster recovery, peak performance, and clean energy."  And who hasn't been to a race where, much like a back alley in the old days, you are handed a bottle or packet you've never seen, from someone you don't know, and get the few seconds of why this is best for you?  

My request, in light of products like deer antlers, in which testimonials abound but strong science does not, is that you think carefully before buying/taking anything that doesn't have the strong backing of the scientific community.  At worst it could be ineffective and cause you to fail a random drug test.  And money spent on unknown products is money not spent on  a Power Tap upgrade.  Or, dare I say it, one's wife/husband/boy or girlfriend.  At best, it will give you expensive urine.  

If you're uncertain, keep that credit card in your pocket.  And don't let me catch you scraping the antlers of a deer killed by a truck on the highway.

Images 1, 2 Google images