Thursday, March 27, 2014

Accepting Thank Yous. Athletes Are No Good At It

The Grateful Patient (or Triathlon Race Fan)

Ironman race fans line the course, waiting

“….he did not know how well he sang, he only heard the flaws.”

                                            Martin Tanner by Harry Chapin

My wife had, in her office recently, a patient whom she’d referred to me 18 years ago for a total knee replacement.  This most significantly obese, manic depressive woman who raises prize winning Labrador Retrievers, of which we have two, noted that after nearly two decades of punishing this knee that it was beginning to give her problems again.

 But, when my wife shared this with me, rather than thinking how much good use this patient had gotten from her prosthesis or that eighteen years was incredible in this situation, two opposing thoughts arose.  When surgeons receive unrequested follow up on a patient regarding something they’ve done in the past their first thoughts are negative.  Unforeseen side effect in our litigious society.  Infection, peri-prosthetic fracture, pulmonary embolism, did I do something incorrectly, and the like.  All glass is half empty stuff.  And when this patient was discharged from my practice many years ago, she was overwhelmingly grateful.  Grateful to the point of tears.

 Perhaps like a rock star used to, conditioned to, acclimated to adulation, we as physicians receive thanks from patients on a daily if not hourly basis and we may occasionally lose sight of the differences we have made in people’s lives.  Our patients offer genuine, sincere appreciation of our help without the expectation of secondary gain.  Successful endurance athletes, to a degree, are the same.

Has the passage of time, and 1,000 thank yous, or race fans cheering "You the man" numbed us to the automatic?   If we look around at our triathlon peer group and see this common response to being cheered do we erroneously think, as Joe Walsh sings, “…everybody’s so different, I haven’t changed…lucky I’m the same after all I’ve been through.”  When you fly down the finishing chute of an Ironman, and the fans want to high five you - yes you - do your own personal thoughts, possibly embarrassment, preclude you from enjoying the moment?  I think the answer is, to some degree, yes for all of us.

 I want to share with you a remarkable letter written to a Primary Care friend of mine who wasn’t even the author’s doctor but a chance medical encounter changed her life forever. You have the same opportunity every time you race, to every child on the race course, many of the adults, and that volunteer in the changing tent who's total focus is you.

Dear Doctor _____

      I am hoping I have contacted the same physician who had patients at Sandy Ridge SNF 2004.   I was a CNA there during Hurricane Ivan in September 2004.  I was working a night shift when I asked you about liver tests because I had overdosed February ’04.  You might not remember me but I will never forget you or lose my gratitude for your advice.  It was obvious I was depressed at the time.  I know I told you I was self-injuring and my friends I was staying with hid their knives.  You said I needed friends like that.  Your advice was to go running; it would help me put color back in my world.  I took your advice and began walk-running.
 September 2006, so two years later, I ran my first marathon and had been out of depression for some time.  A few weeks ago, my husband and fifteen month daughter old and I went to Chicago for me to run my first ultra-marathon, a 50K.  I have also run 9 marathons and feel so much better.  I earned my masters in Speech Pathology ’07 and work on Saturdays in a rehab hospital and during the week I stay home with my little girl.  I know our interaction was very brief but running has saved my life and I thank you for listening and your wisdom.

God bless, Julie ___________

Although letters like this are infrequent, gratitude is not.  Try to take that extra minute to savor peoples appreciation of your triathlon efforts before putting the force shields back in place to do battle with the pain of racing.  Your efforts provide the roll model for those in our society who will not or cannot exercise the way you do.  Although it's a role you only find yourself infrequently, it's one you need to play.  At the end of your career, the grateful patient (or race fan) stays with you.

I’m sure.

IRONMAN Parade of Nations for the fans in Kona.

Big Island Athletes get a special ride in the Parade of Nations.

Thursday, March 20, 2014

Stress Fractures, Yes It Can Completely Break!

Well, I'm running down the road 
Tryin' to loosen my load ..........

I got 7 races on my mind.  

Four that wanna drown me,

Two that wanna crown me, 

one says it's a friend of mine.     The Eagles, Take it Easy 

Jones Fractures 

Although foot fractures, specifically those of the fifth metatarsal, are most common in the cutting sport athlete like basketball or soccer, they do occur quite frequently in the triathlete population.  A fair amount of confusion exists between the common simple avulsion fracture (where the end of the bone is pulled off by the strong peroneus brevis tendon, displaces little, and heals readily with a short period of immobilization,) and the more serious injury where the unlucky triathlete suffers the so-called Jones fracture, one that is infamous for non-union and poor healing.

Sir Robert Jones, a noteworthy physician who practiced over 100 years ago, described what we now call the Jones fracture  having it occur in his own foot. He injured it while dancing around a tent pole at a military party.  He described it as an injury to the bone about three quarters of an inch from it’s end occurring as he “trod on the outer side of my foot, my heel at the moment being off the ground.”   Interestingly, x-ray was only invented 7 years before his injury.  (Initially, exposure time was 2 hours!)

This group of fractures has come to be divided into three types beginning with the relatively common, simple avulsion injury secondary to ankle inversion (like a typical sprained ankle) with no antecedent pain history.  These injuries are usually straight forward and can commonly be treated with a short period of immobilization such as a cast. 

The second type is the most common, a stress fracture which actually breaks all the way through.   Although it’s an acute injury, the athlete when queried will admit to some pain in this region before hand.  This may be somewhat surprising to the reader who may have had an extensive experience with stress fractures in his/her training world but is not familiar with them going on to completely fracture.   Not infrequently, they’ll also displace.  Although if given enough time, this second type will usually heal, but the possibility of the lack of union is high enough that many athletes with this fracture will choose surgery.  This surgery would commonly involve realigning the bone fragments and placing a long screw down the center of the bone.  Surgery requires anesthesia, and, the foot must be immobilized for several weeks post-op.

The last, and worst type of bony injury to the upper 5th metatarsal, is a long standing non-union fracture. It just doesn’t heal. These can be treated with metal screw fixation and bone grafting.  Some can be quite difficult to heal and have resulted in “career ending” injuries for some triathletes.  The take home lesson would be that if one has prolonged pain on the outside of the foot, in the vicinity of the fifth metatarsal, that having it checked out sooner rather than later can help the type A triathlete avoid serious and perhaps devastating injury.  A simple examination including x-rays is all that’s needed for early detection and most likely reduce the potential for a long standing non-union fracture allowing for a non-surgical recovery.   Dr. Jones did not comment on his personal treatment or it’s eventual outcome other than to note in his case “the disability lasted several weeks.”  Looks like he was pretty lucky.  You may not be.

Image #1, Themetapicture

Monday, March 17, 2014

Transition Obstacles -& The Miracle of Triathlon/Running

Gonna tell you a story that you won't believe
But I fell in love last Friday evenin'
With a girl I saw on a bar room TV screen.

Well, I was just gettin' ready to get my hat
When she caught my eye and I put it back
And I ordered myself couple o' more shots and beers.
                                                                                                Jim Croce

If you'd been watching the record setting performance of Australia's Mirinda Carfrae while sitting at Splasher's Grill on Alii Drive, 100 feet from the Ironman finish in October, and you saw this "A" level athlete powering through the marathon finish, ready to take her second World Championship break, and her own course record in the process, you'd put your hat back too!

You gotta love Mirinda Carfrae.  You just do.  Here's a gal who runs a 2:50 marathon after swimming 2.4 miles and riding her bike 112 miles.  She puts in the third fastest run of the day, third of all comers, beating every other woman, and all but two of the men!  Plus, she's recently married a fellow Naval Academy grad.

Go Rinny!...And good luck to you and Tim. We can't wait to cheer you both on again.

Transition Obstacles

And you let a little thing like this slow down your transitions?
I first used this photo in a must read blog on transition improvement last Spring, As we in the North and East are on the cusp of the racing season it would make and excellent review.  The concept is simple.  You may not be the fastest biker in your age group, but if you're the quickest at transitions, you may not have to be.  All it takes is a little practice and you can reduce transitions to practically nothing.

Miracle of Triathlon/Running

Lastly, we all get something different from our sport.  Some athletes aim for weight loss, some a certain level of fitness and still others yearn for the thrill of competition.  We all benefit in some way as we're slowly exiting the weekend race site, numbers still marking our arms and legs, finishers medal round our necks.

But one of my med school chums shared the letter below (slightly modified to protect the identity of the author) and you'll see gratitude for the sport in a way that you might not have imagined.

Dear Doctor _____

      I am hoping I have contacted the same physician who had patients at Glenside SNF 2004.   I was a CNA there during Hurricane Ivan in September 2004.  I was working a night shift when I asked you about liver tests because I had overdosed February ’04.  You might not remember me but I will never forget you or lose my gratitude for your advice.  It was obvious I was depressed at the time.  I know I told you I was self-injuring and my friends I was staying with hid their knives.  You said I needed friends like that.  Your advice was to go running; it would help me put color back in my world.  I took your advice and began walk-running.
 September 2006, so two years later, I ran my first marathon and had been out of depression for some time.  A few weeks ago, my husband and fifteen month daughter old and I went to Chicago for me to run my first ultra-marathon, a 50K.  I have also run 9 marathons and feel so much better.  I earned my masters in Speech Pathology ’07 and work on Saturdays in a rehab hospital and during the week I stay home with my little girl.  I know our interaction was very brief but running has saved my life and I thank you for listening and your wisdom.

God bless, Alice ___________

So tomorrow when your run or swim is a little more challenging than you'd planned remember this letter. Remember this woman, and think about the positive influences you as a triathlete have on the lives of those around you, especially the children.  You put color back in peoples lives!


Image 1, Google Images

Thursday, March 13, 2014

Surgery, Even Athletes Have Operations

Surgery, What If I Need It?

American Tim O'Donnell causes a stir on Alii Drive in Kona
“You’re going to need to have that fixed.”

 “And then the surgeon walked out of the room.” If you’ve never had surgery, being told that the next step in your care involves a trip to the operating room can be a tad upsetting. What’s going to happen to me? How long will it take to get over it? Can I pay for it? Are you sure there isn’t another way to get better?  Hey, I forgot, I’m a triathlete, I can get through anything!  I’d better check with the Dodger and Freaky Fred on the Triathletes Forum for a second opinion.  (So many athletes rely on opinions they get from anonymous sources on line.  In short, don't!)

These and a 1000 other questions run through the mind of the new patient as he/she’s been told, for example, that their shoulder will continue to dislocate while swimming unless something is done surgically to prevent it.  Although it seems difficult, maintaining control of your healthcare is important and having some idea of what questions need to be answered is essential!

Be prepared to discuss the nitty gritty details like agreeing on a date for the operation, where and what time it will take place, pre-op diet, what to wear, pre-op blood or lab work that might be needed, and all the little details that are so important to the patient. In our office this discussion often includes a video about the procedure that helps put the patient at ease. At this stage you’ll be asked to sign the first of several permits giving your consent for surgery.  In our exceptionally litigious society, this is the first document that you’ll see explaining the basic nature of what will happen to you and the basic risks that you will be taking. You’re giving the surgeon permission to do the operation understanding that positive results, while implied and hoped for, are not guaranteed. If you have any doubts, want a second or even third opinion, now’s the time to express that concern! You’re the one having the operation and you need to feel confident about your decision.  It doesn’t bother the surgeon at all if you say you need to delay the procedure to ask around.  In fact some docs actually encourage this. However, there are some operations that get better results when done early, (not delayed.) In my mind as a surgeon, it’s the informed patient who helps me achieve the best results.  We’re a team.

 You’ll also probably talk with your insurance company.  Sometimes you can be surprised  when you learn that the terrific office health insurance policy isn’t so terrific after all.  If things don’t seem right, ask questions.  If it looks like there may be a significant financial burden placed on you, ask about all your options.  Sometimes a monthly payment schedule can be set up for your portion.  And, if it looks like this is an amount out of proportion to what you can afford, don’t be bashful about asking the surgeon to do it for less.  You’d be amazed, particularly in a private office, at how many times the answer to that question turns out to be yes.

Your Day of Surgery

You’ll probably be directed not to eat or drink after midnight the night before to avoid any problems with anesthesia.  You’ll arrive at the hospital/surgicenter an hour or two early, change into one of those funny gowns that opens in the back (don’t worry, even though these gowns are pretty drafty, the staff is really not looking at you even if you think you have a hot triathlon bod – honest, they do this every day and it’s “seen one, seen ‘em all.”)  Then it’s time to meet the staff, sign more permits and prepare for your time in the operating theater.  Surgicenters are very efficient places and they like to stay on schedule.  Arthroscopic cases are usually very predictable time wise. The anesthesiologist discusses the options for anesthesia, helping you pick what’s right for you. In some cases the best option is to be put to sleep (general anesthesia.)  In other cases there’s an advantage to a local or regional block.  Your preference and those of the surgeon are taken into account.  There may also be an IV involved.  And when your turn comes, off you go into a whole new world.

For this article, let’s say you’re headed for wrist arthroscopy for a torn cartilage, a common procedure, and you’ve chosen a block.  You would receive an injection into your arm or shoulder that temporarily numbs  your arm – I’ve had one of these and know it doesn’t hurt.  After this procedure, things start to happen pretty quickly.  Frequently the nurse will put a tourniquet on the operative limb after which application of a germ killing solution and draping begin.  Your surgeon, now gowned and gloved, will say “Hi” just so you know it’s him/her, and the procedure will begin with a test of the anesthesia just to make sure you have absolutely no pain.  Very quickly, the scope will be in your wrist and the images of the inside of your joint seen on the television next to you.  Most folks are fascinated by this.

You can usually watch the surgeon’s progress in real time, while listening to what’s being done and why.  Most surgeons are very receptive to answering your questions while they work.  If any tissue is removed it is customarily discarded.

Once the operation is complete, a dressing is placed on your wrist, you get transferred to the recovery room stretcher, and are wheeled to the Post Anesthetic Care Unit where you’ll remain until the feeling returns to your arm.  It is here that any remaining pain or other issues are solved.  Often the doctor will drop by to make sure you’re OK, discuss the operative findings, and maybe even give you the photographs or a DVD of the bone or tissue that he/she operated on.  You’ll be given a post op appointment before you get dressed and are discharged.  Then, as they say in Good Will Hunting, “Let the healing begin.”

Good luck!

Monday, March 10, 2014

Tomorrows Bike Fit Available Today

Before every ride, in addition to checking your tires, "bounce" your bike. Hold it and inch or two off the ground and let it bounce on both tires listening to the sound it makes.  In short order you'll recognize the tone it's supposed to emit.  If anything's awry, the pitch will be different leading you to investigate why. Is something loose? Might save you from a crash one day.

In just about every triathlon, the greatest time is spent on the bike.  Athletes have known for years that small improvements on two wheels can lead to big dividends down the road. One of our local athletes has been in triathlon a long time. Long enough to have had some significant cycling related pain and dysfunction.  Pain on the bike has, intermittently even kept him from training/racing for periods of time.  He's had several bike fits over the years by some of the best in the business.  His first was with Maryland based Troy Jacobson, then the Official Ironman Coach, and also the driving force behind the Spinervals workout series that's so popular. Some years later he was fit by Lance Armstrong's aerodynamic and fit guru from Texas, John Cobb.  Cobb is a savvy guy, has done thousands of fits, and has such an incredible wealth of experience that he can help just about anyone. (See previous blog 2/21/10.)

Finally, he flew from the East Coast to Boulder, CO to the offices of Dr. Andy Pruitt, author of Andy Pruitt's Complete Medical Guide for Cyclists.  If you don't have this book it's not expensive and can be a ready reference to any cyclist with a bike related physical problem.  Dr. Pruitt and chief technologist Todd Carver were among the first using infrared technology in developing what would ultimately become the Retul Fit System.

While all of these were helpful in their own way, sometimes we just have to wait for technology to catch up. This is where Cyclologic of Scottsdale, AZ comes in.  Rather than bike fit by traditional means, they employ extensive software tools, sensors and computer modeling to achieve the next generation of bike fits.

Massive amounts of data are obtained  and displayed on two large computer screens during the fitting.  The athlete has an active role in this process.  Of particular interest to many is the saddle sensor which displays dynamic saddle pressures in real time while the athlete is pedaling.  This allows changes in saddle position, the entire saddle itself, foot/ shoe position and monitoring the angular nature of the pedal stroke as changes are made.  Owner Paraic McGlynn will tell you that Cyclologic is a Cycling Analysis Solution company

that employs the above technology to give each athlete the fit that's right for them.  He has enough experience that when the hopeful biker wants to look "just like Pete Jacobs," Paraic doesn't buy it.  He and the athlete work through the various factors of positioning and power output to maximize this specific athletes time in

Paraic McGlynn

In short, although this approach isn't for everyone, for our local athlete who'd tried the standard course of fittings, this proved to be just what the doctor ordered.
Thanks to Cyclologic and Paraic McGlynn for their contributions to this piece.

Image 3,4 Google Images

Friday, March 7, 2014

Knee Cartilage, Swelling, Tears and Surgery

Favorite Tweet:  "Dear NSA, as you know, I'm going to sleep now. Can you please tell me if I indeed locked the front door?  Ever thankful, well, u know who."  Author Unknown

Probably the Best Tri Weight Workout You'll Find

Begin by standing on a comfortable surface, where you have plenty of room at each side.
With a 5-lb potato bag in each hand, extend your arms straight out from your sides and hold them there as long as you can.  Try to reach a full minute, and then relax.
Each day you'll find that you can hold this position for just a bit longer.
After a couple of weeks, move up to 10-lb potato bags.  Then try 50-lb potato bags and eventually try to get to where you can lift a 100-lb potato bag in each hand and hold your arms straight for more than a full minute. (I'm at this level).
After you feel confident at that level, put a potato in each bag.

Meniscus Tears

“Say coach, I caught my foot on a tree root running trails this morning and twisted my knee.  It hurt a good bit, and now it’s beginning to swell.  You don’t think I tore the cartilage do you?”

I get a lot of e-mails from athletes following knee injuries.The knee cartilage, or meniscus, is an important structure in your knee.  Menisci, actually, as we have two in each knee, an inside (medial) one and an outside (lateral) one.  They are "C" shaped bits of fibrocartilage also known as semi-lunar cartilages which serve many functions. This is important as it wasn't that many years ago that surgeons felt the meniscus to have no purpose and excised them at will, especially in the pre-arthroscopy days.  Some of you no doubt can remember that HS athletic injury by looking at the sizable scar on your knee from your open menisectomy (excision).  Retrospectively, that may not have been the best thing for these knees.

It's currently felt that the meniscus aids in the lubrication of the joint, stress transfer from femur to tibia, and that it contributes to the stability of the knee. Unless injured, the meniscus will provide a lifetime of service to it's owner without complaint. That said, through injury, arthritis or just plain bad luck, any among us may suffer a "torn knee cartilage."  As was true for both Tom Brady and Tiger Woods, the tear can accompany injury to one or more major ligaments. Usually bad news, this can be a career ending injury.  Even a triathlon ending injury.

Frequently, the injured triathlete will have a physical exam by his/her physician, x-rays and/or an MRI to make the diagnosis. When swelling is present, it’s not uncommon for the examining surgeon to extract some for lab analysis.  If a tear is identified, commonly arthroscopy will follow to remove or repair the damaged meniscus. (In highly selected cases, a meniscus transplant may be considered when more traditional methods have failed.) The arthroscopy is done in the sterile environment of the operating room under a variety of types of anesthesia - most of my patients watched theirs on the TV in the operating theater!  The scope is introduced through two 1/4" punctures which rarely even need stitches at the end of the procedure. Oftentimes the surgery is completed in under an hour, there are no crutches, and rehab exercises are begun in the recovery room.

The surgeon who's seen the inside of your knee is likely in the best position to determine your return to sport, possible limitations, etc. but recovery from an arthroscopy for an isolated is usually pretty quick in the motivated triathlete.

Take good care of your menisci, they should last a while!

Image 1, Google images,

Monday, March 3, 2014

Dealing With Injuries, We All Have Them - (And, Yes, More Snow)

The Triathlon Early Season - Yep It's March Already
Any problems with riding today?  And we're expecting 6 more inches of snow.

The first Ironman.  Only 13 finishers T-shirts that year!  Valuable gear.

Manning, Wilson, and Brady in heaven...

God is eating dinner alone. Peyton Manning approaches the table
and God asks "What do you believe?" Manning says, "I believe in
hard work, and in staying true to family and friends.” God
can't help but see the goodness of Manning and offers him a
seat to his left.

Russell Wilson walks up and God says, "What do you
believe?" Wilson says, "I believe in your total goodness, love
and generosity and that you have given all to mankind.” God is
greatly moved by Wilson’s eloquence, and offers him a seat to
his right.

Finally, Tom Brady comes over to the table: "And
you, Tom, what do you believe?" Tom replies, "I believe you're
in my seat.
(Yeah, I know it's not new, but I like it anyway.)

Dealing With Injuries Psychologically

     The personality issues associated with an injury can be quite depressing.  “It’s a stress fracture, I don’t want you to run for 6 weeks,” as an example.  Often times, when hearing this, the athlete’s initial reaction is a flood of tears!  Or patent denial.  The athlete informs the care giver that he/she is terribly close to qualifying for Boston and has the perfect race scheduled shortly.  They can’t possibly put their sport on hold.
    When injured and told to decrease or eliminate that activity which gives them joy and a sense of purpose, the triathlete sees a piece of themselves being taken away.  Some even believe that the restriction will last forever, like an image in facing mirrors at the barber shop, and they are losing personal control.  It can be complicated dealing with the emotional ups and downs that accompany athletic trauma.  Friendships through the sport are temporarily put on hold and the daily enjoyment/refreshment of the work out is lost.  One’s sense of achievement or identity is removed and it can be a bitter pill to swallow.  In many cases, understanding the emotional impact is as crucial as understanding the physical nature of the problem.  When the damaged body part requires a prolonged rehab and recovery, at least a light at the end of the tunnel can be seen.  But occasionally, when surgery is required or a season ending problem is diagnosed, down right depression can be the result.

    If an athlete is part of triathlon long enough, it’s virtually guaranteed that something will be injured at one time or another.  Some, unfortunately, many times as they bring previous medical and physical baggage with them with their desire to achieve.  So, if some type of pre-injury preparedness is undertaken the emotional blow can be lessened.  An effort is made to fill the daily time block allotted for training in some fulfilling way as this will soften the blow.  LifeSport coach Lance Watson compares this grief reaction to that of researcher Elisabeth Kubler-Ross who defines five stages of loss from her pioneering work with the terminally ill.  These are denial, anger, bargaining, depression and acceptance as seen in her classic text On Death and Dying.  If you think about this for a minute you’ll see that it’s quite applicable in this instance.  Indeed the injured party has lost the ability to race and train, possibly through no fault of their own.  Watson tells us to “reframe the injury.”  View it as an opportunity to work on our triathlon limiters in other areas.  He states, “Do as much as you can to solve the problem each day even if it’s only stretching and icing.”  Do your part so to speak. We’re told to “stay involved with what you love.”  Can you help out at local races, assist in set up, body marking, be a volunteer? It can also be a time to take care of things you’ve put off like chronic bike discrepancies and maintenance, repairing your rain gear or reading up on nutritional or recovery advances.  Finally, “look for the silver lining.” If you’ve been diagnosed with an issue that prevents you from running, perhaps you can make a short term “single sport block” as taught by Phoenix based tri coach Ryan Riell.  View this as an opportunity to ramp up a very select part of your training to accomplish something that’s been holding you back in the past.  This will also force you to take ownership of the injury and increase your knowledge base as to the source of this type of damage.  It follows that it becomes your responsibility to ensure that the potential for recurrence is minimized.  In most all cases, the issue will be resolved and you’ll be back on the street in racing form.

And, you’ll also be a wiser triathlete.

Kona is home the Hawaii International Bill Fishing tournament.