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

Sunday, November 24, 2013

Finger Fractures, A Bigger Deal Than You Think/Glucosamine Helpful?


Fractures of the Fingers






Glucosamine For Joint Pain?  I get asked fairly regularly about whether there's any merit to using glucosamine, or glucosamine and chondroitin as it's frequently sold as a dietary supplement in this country.  Sadly, even though it's sometimes labeled as shark cartilage, no studies to date have shown it any more helpful in those with joint pain or arthritis than placebo.  (Maybe it's helpful to sharks.)  The standard line you hear from most orthopedists is that it won't harm you when taken in recommended amounts but like so many of the supplements sold to the triathlon population, it will give you expensive urine and little else.


If you think a broken (fractured) finger is a minor injury, think again. Without proper treatment a fractured finger can cause major problems. The bones in a normal hand line up precisely. They let you perform many specialized functions, such as grasping a pen or manipulating small objects in your palm. When you fracture a finger bone, it can cause your whole hand to be out of alignment. Without treatment, your broken finger might stay stiff and painful.Your hand contains 27 bones.


There are 8 bones-the carpals-in your wrist. The palm of your hand contains 5 bones called the metacarpals. The 14 bones in your fingers are called the phalanges. Fractures to the metacarpal bone that leads to your little finger accounts for about one-third of all hand fractures in adults.

Generally, a fractured finger occurs as the result of an injury to your hand. You can fracture a finger when you slam your fingers in a door or put out your hands to break a fall. You can fracture a finger during a ball game if the ball jams your finger. Carelessness when working with power saws, drills, and other tools can result in a fractured finger.


  • Swelling of the fracture site.

  • Tenderness at the fracture site.

  • Bruising at the fracture site.

  • Inability to move the injured finger in completely.

  • Deformity of the injured finger.


If you think you fractured your finger, immediately tell your doctor exactly what happened and when it happened. Your doctor must determine not only which bone you fractured, but also how the bone broke. Bones can break in several ways. They can break straight across the bone, in a spiral, into several pieces, or shatter completely.

Your doctor may want to see how your fingers line up when you extend your hand or make a fist. Does any finger overlap its neighbor? Does the injured finger angle in the wrong direction? Does the injured finger look too short? Your doctor may X-ray both of your hands to compare the injured finger on your uninjured finger on your other hand.


Nonsurgical Treatment

Your doctor will put your broken bone back into place, usually without surgery. You'll get a splint or cast to hold your finger straight and protect it from further injury while it heals. Sometimes your doctor may splint the fingers next to the fractured one to provide additional support. Your doctor will tell you how long to wear the splint. Usually a splint on a fractured finger is worn for about three weeks. You may need more X-rays as you heal so your doctor can check the progress of your finger as it heals.

Surgical Treatment

Depending on the type and severity of the fracture, you may need surgery to have pins, screws, or wire put in place to hold your fractured bones together.


Begin using your hand again as soon as your doctor determines it is okay to move your finger. Doing simple rehabilitation exercises each day will help reduce the finger's stiffness and swelling. You may be required to see a physical therapist to assist you in these exercises.

For more information on fractured fingers, including symptoms and treatment, talk with your orthopaedic surgeon.


Image 1, Entertainmentmesh.com

Thursday, November 21, 2013

Bat Bites, Cat Bites, Dog Bites, ?Bear Bites? While Training


A Marine was deployed to Afghanistan. While he was there he received a letter from his girlfriend. In the letter she explained that she had slept with two guys while he had been gone and she wanted to break up with him. AND, she wanted pictures of herself back. So the Marine did what any squared-away Marine would do.

He went around to his buddies and collected all the unwanted photos of women he could find. He then mailed about 25 pictures of women (with clothes and without) to his girlfriend with the following note: "I don't remember which one you are. Please remove your picture and send the rest back."


Animal Bites

Each year millions of people in the United States are bitten by animals. Most bites occur on the fingers of the dominant hand, but animal bites can also occur about the head and neck area.  On a Winter morning training run a few years ago in the pre-dawn dark, I was about a half mile from my house.  I know the roads so I have no head light and totally started when a bat tried to land on my head!  I turned around immediately and upon removal of my knit cap once home, my wife could see the faint claw marks in my scalp.  You talk about your surprises!

I finished the run.



 Most animal bites are from dogs. Cat bites are the second most common cause of bites. The risk of infection from a cat bite is much higher than a bite from a dog.

A major concern about an animal bite is the possibility of rabies. Because most pets in the United States are vaccinated, most cases of rabies result from the bite of a wild animal, such as a skunk, bat, or raccoon. Only a few people die from rabies in the United States each year, and most deaths are due to bat bites. In other countries, dog bites are the most common source of rabies. Rabies causes an estimated 55,000 deaths worldwide each year.

Even if a bite does not break the skin, it may cause crushing and tearing injury to underlying bone, muscles, tendons, ligaments and nerves. If the skin is broken, there is the additional possibility of infection.

Signs of an infection include:

  • Warmth around the wound

  • Swelling

  • Pain

  • Discharge of pus

  • Redness around a puncture wound


Signs of damage to tendons or nerves include:

  • An inability to bend or straighten the finger

  • A loss of feeling over the tip of the fingerA physician should be contacted and told how the bite was received and to ask what treatment is needed. The physician will wash the wound area thoroughly and check for signs of nerve or tendon damage. The arm may be examined to see whether there are signs of a spreading infection.

Immediate First Aid

The bitten area should not be put into the mouth. The mouth contains bacteria, which can cause infection.

Superficial Wounds

For superficial wounds, the area should be washed thoroughly with soap and water or an antiseptic, such as hydrogen peroxide or alcohol. An antibiotic ointment should be applied and the wound should be covered with a nonstick bandage.

The area should be watched carefully for signs of damaged nerves or tendons. Some bruising may develop. The wound should heal within a week to 10 days. If it does not, or if there are signs of infection or damage to nerves and tendons, medical help should be sought.

Presence of Bleeding

Direct pressure should be applied to the area using a clean dry cloth and the area should be elevated. If an area is not actively bleeding, it should not be cleaned.

The wound should be covered with a clean sterile dressing and medical attention should be sought.

If the wound is to the face, head, or neck, medical help should be sought immediately.

Medical assistance

The physician will probably leave the wound open (without stitches), unless there is a facial wound. Xrays and a blood test may be needed. A tetanus shot and a prescription for antibiotics may be prescribed.

If the tendons or nerves have been injured, a specialist may be consulted for additional treatment.

The incident should be reported to the public health department. They may ask for assistance in locating the animal. This is so that the animal can be confined and observed for symptoms of rabies.

*Sent to me by a U.S. Marine, veteran of the war in Afghanistan.   Thanks for serving!

Sunday, November 17, 2013

Cold Hands/Feet While Training, Fix 'Em; and How Drug Companies Screw You


"You can have my gun when you pry it from my cold, dead hands."  Men in Black, Edgar (Vincent D'onofrio)




 I cover this topic every year as new readers sign on.

Although it’s not yet December, we in Virginia have had our first snow of the year. I think it’s a good time to start this year’s discussion of cold hands, Raynaud’s Syndrome in some cases.

 Raynaud's is pretty common. Many, unknowingly, will have it as an isolated phenomenon and in others, it accompanies a more global process. Those affected will have more issues in the cold conditions than warm, their fingers will have decreased sensation and turn white, almost snow white, on occasion. When placed in modestly warm water for 2 or 3 minutes, the digits re-warm and turn every shade of red and purple you can imagine before simply settling on only mildly red. Once warm, starting a car is easy.

 If you want to document this, next time it occurs, start taking pictures with your cell phone, and save them for your health care provider. You will be asked about a family history of certain kinds of arthritis, bowel disease and the like. You may find that your complaints are the same (or different) but it's a good starting place.

 My sister and I both have this to a greater or lesser degree and I think I'm the biggest local purchaser of chemical hand warmers at our local backpacking store. But, I ride outdoors all year unless there's snow or ice on the road. Outdoor swimming in winter, however, can present a certain challenge!  Fortunately most triathletes avoid outdoor swimming and the thought of cold water drives them positively - indoors!

 For those readers who may not know (or who may have it and wonder), Raynauds Syndrome is the discoloration and numbness of the fingers that many adults see in response to cool/cold (or sometimes changes in emotion.) The finger whiteness discussed above, sensory disturbance, and even pain, make them pretty useless when trying to type or any other fine motor activity. In a few minutes, as the fingers begin to warm, they turn blue then a purple-red with a "pins and needles" feeling before they normalize. This whole process can take from just a few minutes to an hour and can be quickened by immersing ones hands in warm water as noted above. Or stick them in your pants.   Women seem to get this more than men, 2nd to 4th decade of life. There are medical answers to this, and especially medicines to avoid, which might increase the frequency of attacks.

 That said, I've had it for 30 years, my Mom longer, so it's easy to follow long term. And mostly we just live with it. I use chemical hand and foot warmers biking in the winter, and when it's below freezing I have some Sidi rechargeable warming inserts for my winter biking boots (they're not cheap and don’t work all that well - read don't waste your money). It's all just a matter of preparation. So, welcome to the world of Raynauds Syndrome, it's an inconvenience but not much more.

 A number of readers have had excellent posts about how to solve the cold hands problem that can accompany winter riding. Excellent suggestions have come forth about a variety of different types of gloves/mittens/socks, chemical hand warmers, etc. Some athletes have simply chosen to ride indoors until the bloom of Spring and give those Computrainers a work out. If, however, you want to stay outside all winter, depending upon your climate, some alterations may be in order to remain comfortable.


 A surprising number of athletes suffer from Raynaud's Syndrome.  Physiologically, it's a spasming of the small arteries in the digits, often when cold. About 5% of men and 8% of women have Raynaud's and it can affect ears, toes, and even your nose.

 So, to remain comfortable we have to remain warm. All it takes is a little trial and error. Well, maybe a lot of trial and error. I'd suggest you start by putting a thermometer outside your window to get an accurate temperature before you venture out. It's better than the Weather Channel as you may live a real distance from where they get their measurements. Then, get an idea of what gloves, layering of gloves, mittens and layering/lining of mittens you need at 50 - 55 degrees, 40 - 45 degrees, etc. If your mittens are so bulky that you may lose control of the bike, figure out something else. A reader from last year noted that the important thing was not to layer each digit as you might do with shirts and coats, but to provide a “den” for the fingers. Mittens, more than a single layer, with touching digits and some type of warmer seemed best for him. One thing that many over look is a product called Bar Mitts (they also have Mountain Mitts for your mountain bike.) These are sleeve-like neoprene that fit right over your handle bars and block cold, rain and snow...not that you'll be riding outdoors on 23 mm tires in the snow. I hope. You don't even need very thick gloves to stay toasty. I'll admit that they may look a little dorky but the bike group conversation will quickly move on to something else and you keep your hands warm. I'll attach a couple pictures from a local riders bike. 


 One follower offered  "I've found disposable hand warmers to be essential for winter running -- I start using them when the temperature drops below 50. For running races, I wear thin gloves, then hand warmers, and then socks over both. If I heat up too much in the race, I can toss the socks or even the hand warmers."


How the drug company Sxxxxx is killing you (and me)

Sxxxxx pulls Cyyyyyyy off the market to clear way for higher-priced Lzzzzzzz

Thought you might be interested in this. Sxxxxxx can make a lot more money using Cyyyyyyyy for the treatment of MS than for cancer. BUT, Sxxxxx would not be able to charge as much for using Cyyyyyy in MS as the other MS drugs (Cyyyyyy has been out a while for the treatment of cancer so the price was already set).

 Solution: Several months before Cyyyyyy gets approval from the FDA for the treatment of MS, they remove it from the market. Then, when it gets approval for MS bring it back under a different name at a much, much, much higher price.

 Got to love those drug companies.


Tuesday, November 12, 2013

Compartment Syndrome


Compartment Syndrome

Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage.

Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion.


Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.

The area between the knee and ankle has four major muscle compartments: anterior, lateral, superficial posterior, deep posterior.

Figure A: Reproduced and adapted with permission from Gruel CR: Lower Leg, in Sullivan JA, Anderson SJ (eds): Care of the Young Athlete. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000. Figure B: Reproduced and adapted from The Body Almanac. © American Academy of Orthopaedic Surgeons, 2003.



Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome.

Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.


Acute Compartment Syndrome

Acute compartment syndrome usually develops after a severe injury, such as a car accident or a broken bone. Rarely, it develops after a relatively minor injury.

Conditions that may bring on acute compartment syndrome include:

  • A fracture.

  • A badly bruised muscle. This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player's helmet.

  • Reestablished blood flow after blocked circulation. This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. A blood vessel can also be blocked during sleep. Lying for too long in a position that blocks a blood vessel, then moving or waking up can cause this condition. Most healthy people will naturally move when blood flow to a limb is blocked during sleep. The development of compartment syndrome in this manner usually occurs in people who are neurologically compromised. This can happen after severe intoxication with alcohol or other drugs.

  • Crush injuries.

  • Anabolic steroid use. Taking steroids is a possible factor in compartment syndrome.

  • Constricting bandages. Casts and tight bandages may lead to compartment syndrome. If symptoms of compartment syndrome develop, remove or loosen any constricting bandages. If you have a cast, contact your doctor immediately.

Chronic (Exertional) Compartment Syndrome

The pain and swelling of chronic compartment syndrome is caused by exercise. Athletes who participate in activities with repetitive motions, such as running, biking, or swimming, are more likely to develop chronic compartment syndrome. This is usually relieved by discontinuing the exercise, and is usually not dangerous.


Acute Compartment Syndrome

The classic sign of acute compartment syndrome is pain, especially when the muscle within the compartment is stretched.

  • The pain is more intense than what would be expected from the injury itself. Using or stretching the involved muscles increases the pain.

  • There may also be tingling or burning sensations (paresthesias) in the skin.

  • The muscle may feel tight or full.

  • Numbness or paralysis are late signs of compartment syndrome. They usually indicate permanent tissue injury.

Chronic (Exertional) Compartment Syndrome

Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides when activity stops. It most often occurs in the leg.

Symptoms may also include:

  • Numbness

  • Difficulty moving the foot

  • Visible muscle bulging

Doctor Examination

Acute Compartment Syndrome

Go to an emergency room immediately if there is concern about acute compartment syndrome. This is a medical emergency. Your doctor will measure the compartment pressure to determine whether you have acute compartment syndrome.

Chronic (Exertional) Compartment Syndrome

To diagnose chronic compartment syndrome, your doctor must rule out other conditions that could also cause pain in the lower leg. For example, your doctor may press on your tendons to make sure you do not have tendonitis. He or she may order an X-ray to make sure your shinbone (tibia) does not have a stress fracture.

To confirm chronic compartment syndrome, your doctor will measure the pressures in your compartment before and after exercise. If pressures remain high after exercise, you have chronic compartment syndrome.


Acute Compartment Syndrome

Acute compartment syndrome is a surgical emergency. There is no effective nonsurgical treatment.

Your doctor will make an incision and cut open the skin and fascia covering the affected compartment. This procedure is called a fasciotomy.

Sometimes, the swelling can be severe enough that the skin incision cannot be closed immediately. The incision is surgically repaired when swelling subsides. Sometimes a skin graft is used.

Chronic (Exertional) Compartment Syndrome

Nonsurgical treatment. Physical therapy, orthotics (inserts for shoes), and anti-inflammatory medicines are sometimes suggested. They have had questionable results for relieving symptoms.

Your symptoms may subside if you avoid the activity that caused the condition. Cross-training with low-impact activities may be an option. Some athletes have symptoms that are worse on certain surfaces (concrete vs. running track, or artficial turf vs. grass). Symptoms may be relieved by switching surfaces.

Surgical treatment. If conservative measures fail, surgery may be an option. Similar to the surgery for acute compartment syndrome, the operation is designed to open the fascia so that there is more room for the muscles to swell.

Usually, the skin incision for chronic compartment syndrome is shorter than the incision for acute compartment syndrome. Also, this surgery is typically an elective procedure -- not an emergency.

Sunday, November 10, 2013

Updated Caffeine and Aspirin Recommendations for Endurance Athletes, 2014

This article summarizes current philosophy regarding racing fluid replacement, aspirin and caffeine dosing, etc.

You're never too old to learn.  For the years prior to the quantification of hyponatremia, low sodium in the blood stream, or EAH (Exercise Associated Hyponatremia) in the ground breaking work of Mitch Rosner, MD at the University of Virginia, I followed the recommendation of the Ironman Official Coach to sip water constantly race morning,  and peeing just before the gun so that I'd be "tanked up."  That methodology has since been disproved, and drinking fluids to excess can even be lethal, so that while popular in 1993, in 2013 it is discouraged.  There's still a good bit of debate between those who say "drink only to thirst" and others who believe that each individual needs his/her own fluid management plan based on personal experience.  While I follow the teaching of Doug Casa at the Korey Stringer Institute and favor the latter, that's an argument for another day.

Moving on, I have preached, and been part of an Australian study during the Ironman in Hawaii, caffeine loading.  I've also written that it remains one of the few legal performance enhancers and how one should calculate a personal dosing schedule during Iron distance racing, make the first dose about 500 mg, etc.  Looks like current research may refute this concept as well depending on one's goals.

I have followed the literature regarding death in triathlon for years and came across the piece below on Twitter. It's reproduced in it's entirety.  My request is that, while this is the author's best guess for 2013, knowing further experience and research will modify these recommendations, that you take just a moment to pass this on to all of your older endurance athlete friends be they runners, swimmers, triathletes, whatever.  If by disseminating this evidence we can prevent a single death, that athlete and his/her family would be eternally grateful.

Please remember when you are evaluating this or any other data, don't just take what an author says for granted.  We triathletes are bombarded by claims from deer antler spray to the latest make you faster supplement.   The data on marathons and cardiac events is based on observational studies. So not the same strength as having a randomized study with matched controls or some huge Framingham database. Though most all the authors seem to come to the same conclusion that there is an increase in cardiac events. However, as pointed out in the New England Journal of Medicine by Kim, the incidence is really small and aspirin may have limited efficacy (page 139, 1/12/2012).  So perhaps not a consensus on taking an aspirin. Though you have to wonder if there is any danger in a single aspirin before a race.

Thanks, John Post, MD 

Running Doc: Research proves that limiting caffeine &  taking a baby aspirin can help prevent sudden death 



The Running Doc addresses the issue of sudden death among marathoners and other long-distance athletes, advises limiting caffeine and taking a baby aspirin the day of the event, cites published research.

Dear Running Doc:

I know you have recommended limiting caffeine and taking a baby aspirin race day to prevent sudden death.

Yet with the recent deaths we have seen in the news, like at the Rock 'n' Roll Half Marathon in Virginia Beach, being a 45-year- old runner planning to run the NYC marathon, I went to my doc for a check up. All my tests were normal including a stress test but my doc said there is no scientific evidence to support what you suggest so he did not recommend it! What should I do? Jerry P. New York, NY.

Dear Jerry:

Thank you for your question. With all due respect, your doc is absolutely wrong. The recommendations of the International Marathon Medical Directors Association (IMMDA) are a no-brainer for someone with no medical problems and recent published research backs them up. IMMDA docs are medical directors for endurance events throughout the world and made recommendations based on interviewing successfully resuscitated victims and from autopsies of sudden deaths at our events. The recommendations are presented at the end of the column again with IMMDA’s permission. They can also be found here: http://www.aimsworldrunning.org/articles/IMMDA_Sudden_death_and_how_to_avoid_it_3.20.10.pdf

Dr. Arthur Siegel, from McClean Hospital in Boston, is a leading researcher on sudden death in long distance running and a consultant to IMMDA. He published his results of groundbreaking research in 2013 in the World Journal of Cardiovascular Disease (2013, 3, 17-20). His work gives the scientific evidence to back up the IMMDA recommendation.

He concluded: "The increased risk for cardiac arrest and sudden death during marathon running occurs predominantly in middle-aged males with previously silent coronary heart disease. The use of pre-race low-dose aspirin is evidence- based by validated clinical paradigms to protect such runners from acute cardiac events during races triggered by high, even if transient, atherothrombotic risk."

Similarly, research has been published regarding limiting caffeine to less than 200mg on the morning of a long run. The article: "Caffeine Reduces Myocardial Blood Flow During Exercise" by John P. Higgins, Kavita M. Babu in The American Journal of Medicine (Vol.126, Issue 8) http://www.amjmed.com/article/S0002-9343%2813%2900189-7/abstract?source=aemf also is scientific published evidence supporting our recommendations.

And events are starting to recognize these recommendations and getting the word out. Dr. Paulo Afonso Lourega de Menezes, an IMMDA, has arranged for his Rio marathon to be the first major marathon to fully endorse these recommendations.

So Jerry, I feel comfortable telling your doc he/she is wrong and that to decrease the risk follow our most basic recommendations:

1. Participants should not only be sufficiently trained, but equally important, they should have a goal and corresponding race plan that is appropriate for that level of training and fitness. If not, do not attempt the distance.

2. Have a yearly physical examination and be sure to discuss your exercise plans, goals and intensity at that visit.

3. Consume one baby aspirin (81mg) on the morning of a long run/walk of 10k or more if there is no medical contraindication.

4. Consume less than 200mg caffeine before and during a 10K or more.

5. Only drink a sports drink or its equivalent during a workout of 10k or more.

6. Drink for thirst.

7. Do not consume a NSAID during a run or walk of 10k or more.

8. Consume salt (if no medical contraindication) during a 10k or more.

9. During the last mile, maintain your pace or slow down; do not sprint the last part of the race unless you have practiced this in your training. Run/walk as you train.

We wish you and every one running a great, safe and healthy NYC marathon.And PLEASE follow these recommendations.

Lewis G. Maharam, MD

Thursday, November 7, 2013

Testosterone Therapy Found Not Completely Safe

Should you be worrying about low testosterone ?

                              Probably Not.

Is it safe to take it anyway, or because a guy in my bike group does?         No, not in all of us*.



 This was posted by WTC on Twitter and will be the highlight of your day. "What's Your Fitness Age?"



One more thing you may have missed : WR holder David Rudisha is taken down by not one but TWO young Irish track stars  http://vimeo.com/77528958

To be fair, it was a smaller track and they might have used their lower centers of gravity to their advantage.


Low T -  In June I wrote a piece on testosterone called, "Testosterone, Should I? http://tinyurl.com/k2nal4g which contained the following two quotes:

 "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." 


"Much of the medical community finds fault with the seeming epidemic of men with low testosterone levels and the pharm company manufactured 'need for treatment of this condition'."

  There's no need to re-hash the entire piece but, after the NY Times ran the article poo pooing the use of this drug it recieved a number of educated responses, some appear below and bear reading by those who may be considering evaluation and treatment.

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.]

  • M.D.

  • Boulder, CO

I am positively exhausted from having to explain to my middle-age male patients that there is not a sudden epidemic of hypogonadism that they have been made aware of (and are suffering the symptoms of) by a benevolent pharmaceutical company ad. I have this conversation at a minimum of three times daily whereas, prior to last year, I had the conversation, maybe, three times a year. At least my anecdotal experience tells me that direct-to-consumer marketing is efficient use of Pharma dollars.

  • martyr

  • Upstate NY

Let's see - Viagra and Low-T supplements are covered by insurance - but the Congress is objecting to birth control being covered by insurance. The Low-T supplements only require a small co-pay (according to the article) but osteoporosis drugs, such as the one I take with proven medical benefit, has a high co-pay. To top it all off, women's health insurance costs more than men's - something is wrong with this picture....

  • ACW

  • New Jersey

As a woman, I have found, as most smart men and women have, that the most important sex organ is the one between the ears. A man who actually does have low testosterone due, say, to advancing age not only can continue to have a satisfying sex life, assuming the availability of partners and mutual affection, he may actually be a preferable lover, for reasons that need not be spelled out here but which will be clear to anyone who thinks about it. 

Those ubiquitous ads for testosterone cream also list so many side effects (including, women should not come in contact with it)! I'm not sure I'd want to be intimate with a guy who was using it. I'd be scared of getting it on me.

Don't fix what ain't broke. Especially don't risk breaking it in the course of trying to soup it up.

  • Julie McNamara

  • San Diego, CA

Really? Does anyone really believe this world needs more testosterone ? Humans need to get way better at managing the amount that's already floating around out there.


*Is it safe?

  In the current issue of the Journal of the American Medical Association there's a research article about "Testosterone Therapy and Mortality, MI and Stroke".  In a study performed in veterans, testosterone was "associated with increased risk of mortality, MI, or ischemic stroke."  They also suggest further randomized trials to characterize the potential risks of testosterone therapy and I agree.  Whether these findings are applicable to every man who uses testosterone isn't known but it's a great big red flag that testosterone may be anything but risk free.