Wednesday, January 29, 2014

Bicep Tendon Tear, Shoulder, Part 1

The bicep tendon.  It can tear in old triathletes and young triathletes alike.  What, if anything, do we do about it?  This is presented in two parts where today we discuss pertinent anatomy and tear types. Part 2 will be tear types, symptoms and what to do about it.

Mayhem for certain. Mass swim start combat.

Biceps Tendon Tear at the Shoulder
The biceps muscle is in the front of your upper arm. It helps you bend your elbow and rotate your arm. It also helps keep your shoulder stable.
Tendons attach muscles to bones. Your biceps tendons attach the biceps muscle to bones in the shoulder and in the elbow. If you tear the biceps tendon at the shoulder, you may lose some strength in your arm and be unable to forcefully turn your arm from palm down to palm up.
Many people can still function with a biceps tendon tear, and only need simple treatments to relieve symptoms. Some people require surgery to repair the torn tendon.

There are two attachments of the biceps tendon at the shoulder joint.
Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).
The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.
The upper end of the biceps muscle has two tendons that attach it to bones in the shoulder. The long head attaches to the top of the shoulder socket (glenoid). The short head attaches to a bump on the shoulder blade called the coracoid process.

Biceps tendon tears can be either partial or complete.

A complete tear of the long head at its attachment point in the glenoid.
Partial tears. Many tears do not completely sever the tendon.
Complete tears. A complete tear will split the tendon into two pieces.
In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.
The long head of the biceps tendon is more likely to be injured. This is because it is vulnerable as it travels through the shoulder joint to its attachment point in the socket. Fortunately, the biceps has two attachments at the shoulder. The short head of the biceps rarely tears. Because of this second attachment, many people can still use their biceps even after a complete tear of the long head.
When you tear your biceps tendon, you can also damage other parts of your shoulder, such as the rotator cuff tendons.

Sunday, January 26, 2014

The Triathlete's Value at Work/ Winter Training Blahs/Compression Wear of Little Value?

“If more people ran, fewer would be dying of degenerative heart disease, sudden cardiac arrest, hypertension, blocked arteries, diabetes and most other deadly ailments of the western world.”

                                                                                                             Born to Run

While there may be some minor medical inaccuracies, the sentiment rings true.

As triathletes, our lifestyle may seem a bit odd to some outside the sport.  When noticed as a triathlete, some of us use it as an opportunity for self-promotion, “Ain’t I grand?  Why, yes, those are compression hose under my business suit…how did you ever notice?”  But for most of us, the life choices are about fitting our training in around the schedules of others without being too much of a bother.  And, if we stick out a little, having made a commitment to health, so be it.  Michael J. Fox may have said it best noting, “What other people think of me is not my concern.”  I know one triathlete who makes a habit of doing for others, particularly at work, and the fact that she rides her bike to work…occasionally having stopped by the pool for a couple thousand yards first, makes her all the more valued as an employee who contributes to the bottom line. And not only she thinks so.

In short, others you come in contact with are often a little better for it given your involvement in this sport.  Especially kids.  Keep up the good work.

Winter and Training Blahs

It's 18 degrees outside, snowing, and the roads are a mess.  Anything requiring running shoes or bicycle tires would be a really bad idea.  So if you're an athlete that needs to check that workout completed box every day, some major alterations may be in order.  When we have too many days like this this in a row it can get depressing.  The solution that one of my friends has goes like this. "Buy something!"  Even if it's just a new hat or some brake pads, it make him feel as if he's still contributing toward future success.  A big fan of The Who he likens it to a refrain from the rock opera Tommy:

Did you ever see the faces of the children,
They get so excited,
Waking up on Christmas morning
Hours before the winter sun's ignited.

I don't know if this philosophy works for everyone but I just ordered a couple new Caffelatex flat repair canisters from Colorado Cyclist.  And I do, I do better. (Maybe.) The other thing I learned many years ago was to put out all of the morning's needs before bed.  Any clothing, shoes, toothpaste or shaving cream, coffee in the coffee maker if you partake.  Everything!  So, even if it's right dark and right cold when the morning alarm goes off, the only thing you really need to do is get up, the rest is auto pilot.  And as all of us have found out time after time, once the workout is over, and you're headed into the rest of your day, it all becomes worth it! Really!

So I'm on auto pilot and the gym opens in 47 minutes...treadmill/rowing machine/ex bike here I come.

PS - Pointed out by Dr. Larry Creswell, The Athlete's Heart, recently - worth the time.

From Bicycling Magazine, a piece by Kelly Bastone:

Compression Wear: In a Tight Spot
Manufacturers promise performance and recovery with compression, and cyclists have bought in. But research suggests the benefits are in our heads.

Image credit: Google images

Sunday, January 19, 2014

Aging Up, It Happens This Month - GREAT!

"Hold on to 16 as long as you can, changes come around real soon make us women and men."       John Mellencamp

Yeah, but I age up next year and don't have to race you!!


Every January we get a clean slate.  And a fifth of us get a bonus - aging up.  If you were told before getting into triathlon that getting older, even if it's only one year, is something you were going to look forward to, you'd have likely doubted the speaker's sanity.  But look no further than the 2013 IM Florida numbers to see the obvious.  For example, when thinking about the competitive age groups like 40-44 or 45-49, if you're 49 and 1/1/14 pushed you into 50-54, women go from 137 competitors in the AG to 99 and men drop from 416 to 288 racers.  An even more dramatic shift happens to those turning 55 when the women drop to 31 and the men to 149.  Taking this one more step, if you're a woman and maintain your tri "relationship" one more decade, there will only be four other women in your age group. Woohoo!

And look at 78 year old Harriet Anderson's performance in Hawaii,, a 21 time Kona finisher, the only competitor in her age group.  There's hope for all of us to podium, eventually!

So the new year is here, we're filled with fresh ideas and a positive attitude.  It's time to review 2013, figure out how not to make the same mistakes, and get out there and kick butt!!

Or, in the words of Def Leppard - 

"Rise up, gather round, rock this place to the ground.  Burn it up let's go for broke, watch the night go up in smoke."

Happy racing!


Friday, January 17, 2014

Ingrown Toe Nails/Foot Issues for Triathlon, Part 2

Only 267 training days left till Kona.  Anything slowing you down?

A bit too much snow to ride safely.

"You're never too old or too experienced to learn, or relearn [tricks] and tri training."

                                         Joe Henderson

As triathletes, our lifestyle may seem a bit odd to some outside the sport.  When noticed, some athletes use it as an opportunity for self-promotion, “Ain’t I grand…..why, yes, those are compression hose under my business suit…how did you ever notice?”  But for most of us, the life choices are about fitting our training in around the schedules of others without being too much of a bother.  And, if they stick out a little, having made a commitment to health, so be it.  Michael J. Fox may have said it best noting, “What other people think of me is not my concern.”  I know one triathlete who makes a habit of doing for others, particularly at work, and the fact that she rides her bike to work…occasionally having stopped by the pool for a couple thousand yards first, makes her all the more valued as an employee who contributes to the bottom line.  She's a company woman!

“Cosmetic” Foot surgery, One More Thought

My first blog of the New Year, 1/6/14 concerned the potential of foot surgery in your future and if that were the case, to really think it through carefully.  I had one more thought to add.

The take home lesson here is that while foot surgery, or any kind for surgery for that matter, may be occasionally indicated, the educated patient who’s aware of alternatives and the potential for problems is likely the one who’ll get the best result. But once you've had one operation, a threshold has been met and it's easier to have the second.  Or third one for that matter.  (Michael Jackson, Bruce Jenner, Joan Rivers ring any bells?)  And the combination of Podiatrist, Runner's Doc and running shoe store guy is very potent at modifying shoes, shoe lifts, orthotics, etc. to keep you going.  It may take a little patience but these folks can solve many, many problems - these guys and gals are pros who like to help athletes.

Ingrown Toenail
This is one preventable issue that many people have to lean by messing up.  Don't be one of them.  Just read these simple thoughts.  If you trim your toenails too short, particularly on the sides of your big toes, you may set the stage for an ingrown toenail. Like many people, when you trim your toenails, you may taper the corners so that the nail curves with the shape of your toe. But this technique may encourage your toenail to grow into the skin of your toe. The sides of the nail curl down and dig into your skin. An ingrown toenail may also happen if you wear shoes that are too tight or too short.  Some bike shoes are meant to be tight but get tighter once wet really putting the squeeze on your forefoot.  For $26 bucks, I got a pair of shoe trees* at my local men's store and it's a snap to slip them into my bike shoes after a ride.

An Ingrown toenail.
When you first have an ingrown toenail, it may be hard, swollen and tender. Later, it may get red and infected, and feel very sore. Ingrown toenails are a common, painful condition—particularly among teenagers. Any of your toenails can become ingrown, but the problem more often affects the big toe. An ingrown nail occurs when the skin on one or both sides of a nail grows over the edges of the nail, or when the nail itself grows into the skin. Redness, pain and swelling at the corner of the nail may result and infection may soon follow. Sometimes a small amount of pus can be seen draining from the area.
Ingrown nails may develop for many reasons. Some cases are congenital—the nail is just too large for the toe. Trauma, such as stubbing the toe or having the toe stepped on, may also cause an ingrown nail. However, the most common cause is tight shoe wear or improper grooming and trimming of the nail.

The anatomy of a toenail.


Nonsurgical Treatment

Ingrown toenails should be treated as soon as they are recognized. If they are recognized early (before infection sets in), home care may prevent the need for further treatment:
  • Soak the foot in warm water 3-4 times daily.
  • Keep the foot dry during the rest of the day.
  • Wear comfortable shoes with adequate room for the toes. Consider wearing sandals until the condition clears up.
  • You may take ibuprofen or acetaminophen for pain relief.
  • If there is no improvement in 2-3 days, or if the condition worsens, call your doctor.
You may need to gently lift the edge of the ingrown toenail from its embedded position and insert some cotton or waxed dental floss between the nail and your skin. Change this packing every day.

Surgical Treatment

If excessive inflammation, swelling, pain and discharge are present, the toenail is probably infected and should be treated by a physician (see left image below). You may need to take oral antibiotics and the nail may need to be partially or completely removed (see middle image below). The doctor can surgically remove a portion of the nail, a portion of the underlying nail bed, some of the adjacent soft tissues and even a part of the growth center (see right image below).

Infected nail

Partially removed

Toenail surgery
Surgery is effective in eliminating the nail edge from growing inward and cutting into the fleshy folds as the toenail grows forward. Permanent removal of the nail may be advised for children with chronic, recurrent infected ingrown toenails.
If you are in a lot of pain and/or the infection keeps coming back, your doctor may remove part of your ingrown toenail (partial nail avulsion). Your toe is injected with an anesthetic and your doctor uses scissors to cut away the ingrown part of the toenail, taking care not to disturb the nail bed. An exposed nail bed may be very painful. Removing your whole ingrown toenail (complete nail plate avulsion) increases the likelihood your toenail will come back deformed. It may take 3-4 months for your nail to regrow.

Risk Factors
Unless the problem is congenital, the best way to prevent ingrown toenails is to protect the feet from trauma and to wear shoes and hosiery (socks) with adequate room for the toes. Nails should be cut straight across with a clean, sharp nail trimmer without tapering or rounding the corners. Trim the nails no shorter than the edge of the toe. Keep the feet clean and dry.  Unless, of course, it's RACE DAY!

Proper and improper toenail trimming.

* Shoe Trees

Wednesday, January 15, 2014

Let's Lube That Knee

Synvisc, Orthovisc, Quaker State, Penzoil, 
Non-Steroid Knee Injections

With accumulated wear and tear, or even after trauma, the bone covering articular cartilage of the knee joint can erode.  You know it as arthritis. In addition to the various types of cortisone type preparations which can be injected, a class of agents focused on one of the building blocks of cartilage, hyaluronic acid, is also available for injection.  They are known as hyaluronate preparations and can be effective diminishing both joint pain and swelling.  But before your care giver would even think about this product you'd really want to give a conservative care plan a real chance to work.  Most insurance companies probably wouldn't approve this until then anyway.  In my way of thinking, if you can get better without injecting something into your body I'm all for it.

 These hyaluronic acid agents (Euflexxa, Hyalgan, Synvisc, etc.) can be costly, and as just pointed out, are usually not considered until the patient is a failure to other conservative measures like limb strengthening exercises, Tylenol, possibly a non-steroidal anti-inflammatory drug like ibuprofen (Advil) or naproxen (Aleve,) Physical Therapy, etc.

Once you and your doc agree that this is the next right step for you, an office procedure follows. After sterilely prepping the skin at the intended point of injection, and aspirating any effusion (excess joint fluid) which may be present, the physician takes great care to ensure exact placement into the joint.  Hakuna Matata, "no worries," as you might hear in the Disney's The Lion King, the needle used here isn't all that big and most likely you'll get your skin numbed up.  Whew!  Depending on the product, there can be an injection a week for three weeks, or in some instances, a single injection.  Where I live, the standard is three, but as was pointed out, other than the sting of the needle stick these substances seem to cause very little in the way of pain.  Post injection the patient is asked to refrain  from vigorous exercise (like triathlon!) for 48 hours.

 The success rate in lowering pain and swelling while increasing patient activity levels can be impressive. Upwards of 80% patient satisfaction has been reported.  One company advertises “Over 1.8 million knees treated….and still going strong.”  It can be repeated if/when necessary.  And, if it’s included in a overall program to maintain/preserve knee health as well as forestall a larger procedure like joint replacement, it’s role is clear.  Sadly, since it's not  PED, it won't make you any faster but it may make it so you can train with little or no pain and that's something.

 So, if you have osteoarthritis of the knee, and a hyaluronate is being considered by your care giver, it may be “just what the doctor ordered.” Take it from one who knows.

Sunday, January 12, 2014

Achilles Tendon Tears, the Kobe Update for Triathletes

Achilles Tendon Ruptures

One of my volunteers at bike check in on the Big Island last year was in a walking boot.  But a hard working volunteer none the less.  When I asked what happened, I heard all about his Achilles injury when he tripped over a rock hiking with his kids.

The Achilles tendon is the strongest, thickest tendon in the body connecting the soleus and gastrocnemius to the heel. Men in their 30’s and 40’s seem to have the highest rupture rate, particularly those who are active in sports.  This is especially true of  the weekend warrior who’s relatively sedentary during the work week but really goes at on Saturday . Many in medicine feel that it’s a previously abnormal tendon that ruptures. Although it can fail both at the mid calf level, the junction between the muscle and tendon, or closer to the insertion in the heel, the latter is more common. The tear itself is usually ragged and irregular and not so easy to repair.

The diagnosis is made on physical exam by palpating a space where the Achilles normally resides and a positive Thompson test, squeezing of the calf of the prone patient noting whether or not the ankle flexes. In a failed tendon, the ankle will not flex. Most often, there is little or no warning that the tendon will yield.  If ruptured, running, cycling, and even normal walking just about impossible.  Traditionally, when faced with this injury, a surgical path was chosen to re-approximate the torn tendon ends with stout suture.  Subsequently a period of several weeks immobilization followed to allow the construct to heal.

   Depending upon the severity of the tear and the surgeon’s confidence in the quality of the repair, which I’ve hear described as “sewing moonbeams to flatus,” the athlete can return to running somewhere between 3-6 months post op.  Sort of ruins your whole season doesn’t it?

When diagnosed acutely, options include operative or non-operative treatment, most often the younger population choosing surgery. This could be either a traditional open operation or a percutaneous procedure. That said, there is an increased risk of complication (infection, adhesions, etc.) over those who’ve chosen the non-surgical route but a slightly lower incidence of re-rupture. Following the operation, most patients will be placed in a cast or splint short term followed by a functional brace. Return to sport varies depending on the solidity of the repair, post-op pain, and ability to prevent re-injury.

Over the past several years, an effort’s been made to determine if the current level of success in returning the athlete back to his/her sport can’t just as easily be accomplished without an operation.  This could possibly eliminate the associated complications of post surgical infection, bleeding, nerve damage, etc. and likely lower the cost of treatment.  The beef against non-surgical care has always been that there’s a trade off that by lowering the associated surgical rate of complications you also increase the number of re-ruptures.

One high quality study with 144 patients, half treated with surgery and the others without, showed an almost identical re-rupture rate leading the reader to surmise that either treatment was satisfactory.  However, in the June 12, 2012 Journal of Bone and Joint Surgery, a piece by Dan Bergkvist, MD compared 487 patients from competing hospitals in Sweden.  The re-rupture rate was nearly comparable (3% in the surgical group, 6.6% in those treated without an operation) but there was slightly superior performance and strength testing in the operative group.  This lead the authors to note that surgery “may be beneficial in selected patients.”  In other words, you as an athlete will have a higher demand once “back in the game” and if this unfortunate injury befalls you, surgical repair may still be your best option.  That said, the data would also support your choice of nonsurgical care if you so choose.

Since our goal is to prevent injury in the first place, correction of limb length inequality, arch problems, bio mechanical issues, etc. all help in attaining this. Although there is some controversy, lightly warming up, stretching – both straight legged and bent kneed – perhaps even with a little light massage, coupled with a general fitness program seems to be our best protection in keeping the surgeon at bay.

Image #2 Google Images, Stone

Thursday, January 9, 2014

Can I Afford to be a Long Distance Triathlete?

First off, I want to thank all of the readers.  Since I've come back to Blogger I'm near 1000 hits/day (1014 yesterday.)  You make it more than worth my while, thanks for the attention!

Making it to Kona  (Partially written on the Big Island)
Awaiting Bike Catchers:  Where are those pros, it's hot just standing here.

“Life’s been good to me so far.”  Joe Walsh

“And another one’s gone, and another one’s gone, another one bites the dust, heh heh.”  You know who sang these words.  But, earlier in his career, singer Farrokh Bulsara ( you know him as Freddie Mercury) was going nowhere in a band called Sour Milk Sea.  He took a look at his past, present, and unpromising future and made the changes he felt were required to reach the top.

I guess the question here is are you willing to make the sacrifices Freddie made to get here (meaning Hawaii)?  But first, answer these three questions:  1) Do I have a reasonable chance to qualify or do I just impress myself when I tell others “I’m training for Kona” like you might when telling someone in a bar, "I'm training for the Olympic trials?"  2) Will my personal/professional life suffer too greatly if I take on this goal?  Does your spouse agree with your obviously biased assessment?  3) Is it worth it in the end and what will have been the cost – how many irretrievable kids soccer games will you miss? (The 70.3 distance is to some the perfect race.  It takes a fair amount of training – but not your life - to finish respectably, you’re not walking death the next day…or two, and it’s easy to keep the family involved without dipping into the college savings accounts for airfare.)  In short, can you afford to be an endurance athlete?

Picture the scene, as they say in the song. It's Friday afternoon, the day before the 2012 Ironman World Championship, and I'm standing on the Kona pier with one of the Transition Coordinators named Stu.  He doesn't say much but when he does it's usually spot on. "Will ya look at these bikes?  I couldn't afford a one of them," Stu sighed.  We watched for another few minutes, and after the fourth bike with electronic shifting passed (then costing upwards of $4,000) he said, "You know, sometimes I feel like we're watching the top 2% of society here. Who can afford this sport?"

Well, we may not actually be seeing the top 2% but there's no denying that the successful endurance athlete has probably invested a good piece of change over the last few years to be standing on this pier among the sport's finest.  We are bombarded by ads for running shoes that are $100/pair or well over and being told to replace them every 400 miles.  How about wind tunnel tested race wheels costing thousands, expensive supplements of dubious benefit (ever heard of Deer Antler Spray or the HCG diet, one of three fined $26,000,000 recently by the FDA for deceptive advertising?)

 “The chances of being successful just by sprinkling something on your food, rubbing cream on your thighs, or using a supplement are slim to none," Jessica Rich, director of the FTC's consumer protection bureau, said in a statement. "The science just isn't there."(1)

Who knew?

But I digress.  Race entry is $600 and up for some triathlons and have you seen wet suit prices lately? Whew.  Sexy pics of bikes exceeding $10,000 in several major publications are designed to make the reader feel she'll be off the back without this particular ride.  We've barely scratched the surface and could go on to bike transport, helmets and bike shoes, travel if you need to go to a distant race, etc.

Perhaps a realistic evaluation of ones honest and actual race potential could be a real money saver.  For example my wet suit was used when I bought it 8 years ago.  And since I've haven't gotten any Vaseline on it, the suit works just fine.  My "new" bike is 9 years old.  Maybe, in the words of golfing great Lee Trevino, "It's not the arrows, it's the indian," and although Mirinda Carfrae can make excellent use of a $10,000 bike, can you?

(1) Michael Castillo CBS News 1/7/2014

Monday, January 6, 2014

Dumbest NYr's Eve Story/Planning a 2014 Foot Operation?

On New Year's Eve, a local HS senior, we'll call him Fred, entrusted with Dad's car, had been consuming mass quantities of alcohol. At one point, well before midnight, he found himself alone, passed out in the drivers seat, the car idling - for how long he didn't know.  Then, he remembers nothing until he is awakened at home, in his own bed, by his parents who notice that he's home but the car is not.  "Say son, where's my car?"  He couldn't remember.  But he did remember that he'd left the keys in it....and that, now many hours later, it's still idling!