Friday, January 30, 2015

Sometimes It Comes to Surgery; Your Sesamoids, Dr. R. Roof

"Johnny's life passed him by like a warm summer day."
                                                                                                                   Shooting Star, Bad Company

      Success/even participation in sport can be short lived.  Take advantage of it while you can.  Appreciate your ability to do this and have empathy for those who cannot. As a physician, every day I answer queries from athletes who can no longer do as they wish in sport.  They wish they were in your shoes!

Sesamoid bones outlined in green.

We are very fortunate this week to have the services of a guest blogger, Rodney W. Roof, DPM, FACFAS of Cincinatti, OH.  Dr. Roof is widely known in the dance and sport circles as one who "gets athletes back."  He has a tremendous amount of both non-surgical and surgical foot and ankle experience, and as a high level biker himself, he understands much of the athlete's psyche.  I've asked him to discuss his experience with the painful foot requiring bony excision.  Dr. Roof is a frequent contributor to Slowtwitch and a big Ohio State fan.

With 50 to 75% of weight bearing forces transmitted through the great to joint complex and up to three times body weight with running, sesamoid injuries are not uncommon in athletes. However, many sports practitioners have little experience with them and misdiagnosis can be common. Studies in runners show sesamoid pathology as 4% of all foot/ankle injuries and 12% of the great toe complex injuries.  

The differential diagnosis of plantar great toe joint pathology is large and includes: sprain “turf toe”, capsulitis, gout, flexor tendon pathology, nerve entrapment, plica, sesamoiditis, arthritis of the sesamoid-great toe joint, avascular necrosis (AVN) of the sesamoid(s), or sesamoid fracture.  Most of these injuries will respond to conservative treatment in time, but what if “sick sesamoid syndrome” becomes chronic and surgery is recommended? (JP note: I am asked this question on a near weekly basis.)

The most common cause for sesamoid excision is a fractured or injured sesamoid that remains symptomatic – the newly termed “sick sesamoid syndrome”.  In my experience, an acute sesamoid fracture never fully “heals” on X-rays and is always visible.  However, most are asymptomatic, no longer causing pain, by 6-12 weeks of treatment as the pieces likely form a fibrous union. The “fractured” sesamoid can be seen on X-ray for many years, but requires no treatment. This is important for an athlete to understand since re-injury can occur and new imaging should be compared with old if possible.

My experience (with dozens of sesamoid surgeries performed) is mirrored in the few studies dealing with sesamoid surgery in that I prefer total excision of the affected sesamoid (usually the tibial sesamoid) rather than sesamoid planing or excision of one of the fragments (if fractured or bipartite).  Done properly, the function of the FHB tendon and collateral ligament complex is not disrupted and little to no long term issues are noted.  It is postulated that the development of a hallux valgus (bunion) deformity can be accelerated with removal of the tibial sesamoid, but this has not been my experience, though long term follow-up is often lacking. Most athletes do very well with sesamoid excision today.  The incidence of sesamoid issues occurring on the other foot is not increased post surgery and is the same as before, mirroring the athlete's chosen sport/activity.  Weight bearing is immediate (though heel only or in a CAM boot). Most return to normal shoe gear in 3-4 weeks with some return to training starting at about 6 weeks as tolerated. For runners, little fitness is lost with utilizing an Alter-G treadmill around week 2-3 if available and they are generally running with less great toe joint pain then before surgery by week 12. 

Thanks, Dr. Roof!  So you can see that if told your sesamoid problem needs surgery, make sure you get a doc like Rod Roof who has extensive experience dealing with this problem.  If you don'd know, ask.

Image 1, Bing Images

Wednesday, January 28, 2015

You Might Be an Ironman if........

You Might be an Ironman if...
                                                                                                             (With apologies to Jeff Foxworthy)

1.     The only input you want on the family new car is: not the color, not the warranty, not the gas mileage, just where the bike rack fits.

2.     The bath towel draped over the back of your car's passenger seat never completely dries
3.     Family holidays are chosen for locations, where just by some wacky coincidence, there's a pool, spin class and miles of woodland trails to run or, again just by chance, an IM race to compete in.
4.     You feel guilty, an off day really, if you only get in 2500 yards in the pool.
5.     Your bike is worth more than your car.  In some cases, double!
6.     When someone sees your apartment for the first time, they remark that it looks like the Ironman gift shop.
7.     Your spouse tells you that if the person she's sleeping with doesn't smell like chlorine, she's in the wrong place
8.    When your daughter tells you her college graduation date, you ask if there's a make up date as the local Olympic distance race is the same weekend.  
9.    Overheard at a party, "I'm not worried about my husband having an affair, he might miss a workout."
10.  Each time you dress following a workout you do it as quickly as possible pretending it to be just one more transition zone. Or you find yourself on Sunday in church timing the priest’s homily split.
11.  Your vehicle's interior fairly closely resembles the sale rack at the local tri store.
12.  Even after you have one of those quilts made from old race shirts for your kid, there's still 100+ t-shirts in your dresser
13.  As you head down a congested corridor to business meeting, you have the nearly uncontrollable urge to shout "On your left!"
14.  You find yourself in conversation employing only and 10K in the same context.

Saturday, January 24, 2015

If I Have a Cold Can I Still Work Out?

If I Have a Cold, Can I Still Workout?

Bumper sticker of the unenlightened. 

To me, one of the great things that triathlon adds to your life is structure.  In not a lot of sports does one create an annual training plan (ATP) where, with pretty good specificity, you know what you'll be doing next week, next month, even months from today in an effort to become the best athlete you can be.

But what does an ATP know of "save the date" cards received in February alerting you to a good friends wedding some distance away occurring smack dab in the middle of the weekend where you're supposed to do your very first major brick workout in preparation of your very first 70. race?  Or what happens when one of the kids comes home from daycare and generously gives you the same cold that all the other runny nosed kids there have? Should you still work out?  The opposite side of that question is how to give yourself the best chances at staying well?  This is the flu season after all and we have two problems: 1) we're not at the peak yet, and 2) the strain of flu circulating this year is not contained in this years flu vaccination. Last week I submitted a piece to called

 9 Tips on Not Getting Sick This Winter

which, when published, will probably be titled differently when posted since my boss Jennifer Ward Barber is significantly more creative than I am.  But it's the kind of thing each of us should understand to have the greatest odds at staying well. Check it out.

So to answer the question, if all you have is a common cold, maybe sneezing or a slight sore throat, moderate intensity exercise is doable.  Many find that the moist environment of swimming may actually help clear out the sinuses.  Just make sure you blow your nose before getting in.....particularly if you're in the lane next to me!  We're assuming that you don't have a fever here.  Dr. Mom would say you just have a head cold.  However, once the workout gets started, you need to be prepared for a sort of washed out feeling, that you just can't put the effort into exercise that you desire. Knowing this ahead of time really stems potential disappointment once in the water.  

If you're in the pool, and can't really bust it like you want, don't get pissed off and get out! Forget the planned workout and intervals. Select more kick board yards with fins, drills - you needed them anyway, right? - and maybe just easy straight swimming at a mild to moderate pace making every single stroke a Kodak moment.  The same would be true if running.  If you get out there and you just can't do it, walk.  Think about the folks who, in the 13.1 mile segment of 70.3's or the marathon in an Ironman, plan to walk some.  Yep, a more common strategy than you might think.  For example, one might run 600m and walk 100m, then repeat over and over....for the entire distance.  No reason you can't do that when you're a little under the weather.

If your illness is a little more involved, fever, significant coughing, myalgias - body aches and pains, take the day off.  It just makes more sense to let the body recover before pushing it.

Coach Joe Friel suggests we perform a "neck check."  "With above the neck symptoms...start your workout but reduce the intensity to to Zones 1 or 2 only and keep the duration shorter than usual.  You will probably feel better once warmed up., but if you feel worse after the first few minutes, stop and head home."  He goes on to echo the above when symptoms are below the neck stating, "If the symptoms are below the neck,....or a fever, don't even start."

If I've said it once, I've told patients 10,000 times, let your body be your guide!  Even if all you have is a cold, but you feel lousy, take the day(s) off.  I recently read that you can miss two full weeks of workouts and only lose 8% fitness.  Get back into the swing as you begin to feel better.  If all of this is confusing, it never hurts to ask your doctor just as you would for other medical issues.  So if you're ill and spending a little more time on the couch in front of the tube that usual, this may hit home:

Image 2, Bing images
Image 3, Cartoonist Tim Whyatt, Google images

Wednesday, January 21, 2015

To Detox or Not To Detox, That is the Question: Whether 'tis nobler in the mind to suffer...

Apologies to Shakespeare.

Is a Detox Diet of Benefit to the Athlete?

Detox diets, or diets that promise detoxification are just about everywhere.  A diet plan that may require some amount fasting, juices, water, possibly fruits or veggies with the intent to remove toxins from the body.  Some varieties include a bevy of enemas of various liquids, including the ubiquitous coffee, to cleanse the large intestine of noxious substances.

But do they work?  Is there evidence that the athlete's performance will be positively effected by undergoing some type of detox?  Not likely. Although there are scattered anecdotal claims from users who not as sense of increased energy, focus, etc. there's no backing from the scientific community of their effectiveness.  One explanation followed the no pain-no gain logic that following a period of mild suffering, inconvenience, hunger, possible weakness from mild dehydration, that the restoration of normal phase was one's reward.  Sadly, however, there's scant proof that unknown evil humors have been cleaned from the body.  The kidneys and liver have functioned for millennia to act as a filter and seem to be able to accomplish this in most instances.

This isn't to say that there might not be some benefit to these plans by staying away from sugar and processed foods, consuming only food stuffs which are "good for you," and possibly slight weight loss. But detox certainly wouldn't be considered as part of an intentional weight loss program. 

As for the requirement for enemas, one source noted that the enema will "detoxify the liver and gall bladder, open bile ducts, increase peristalsis, stimulate the digestive tracts, release toxins and help control pain, produce enzyme activity for oxygen uptake, help the formation of red blood cells, give you a 10% improvement in gas mileage and higher resale value on your home."  (Sorry, those last two are mine.  I couldn't help myself.)  The description of this process sounds fun.  "Pre-clear rectum with warm water enema.  Follow this with 32 oz of coffee solution. (Starbucks?)  Retain for up to 20 minutes."  And during those 20 minutes I'm supposed to??  Maybe do 200m run intervals on the 3:00 minutes?

Thus, there doesn't seem to be a need, or value actually, in detoxifying the body.  "Toxins" aren't simply reservoired somewhere, like enemy soldiers, overwhelming the liver and kidneys, waiting to be flushed out.  This would also be consistent with products on the supplement market promising similar lofty goals.

The Mayo Clinic advises us that "Detox, or detoxification, diets are popular, but they're not scientifically proven."  Further, Mayo states that we'd be best off "keeping in mind that fad diets aren't a good long-term solution. For lasting results, your best bet is to eat a healthy diet based on fruits and vegetables, whole grains, and lean sources of protein."  

But you already knew that. enema guidance
Do detox diets offer any health benefits? Katherine Zeratsky, R.D., L.D. Mayo Clinic 

Images, Google Images

Sunday, January 18, 2015

Racing After Joint Replacement: Bad Idea?

"Three and Out is Three and out."  Casey Stengel, Manager, N.Y. Yankees, 1949 - 1960

"Yeah I have some arthritis but I'll just push it until it wears out, get an artificial joint, and keep racing."  This theme, or something like it has been the subject of several blogs here over the past several years.  The usual  take home is that life doesn't work that way.  Regardless how good a joint replacement is, it does not equal the "original equipment from the manufacturer."  

But there is hope for the athletes of the on, it might be you.

When I lecture to other physicians, I often use Floyd Landis as an example. Whether or not you agree with his tactics to wear the yellow jersey in Paris*, for the purposes of this discussion he makes and excellent example. Briefly, while a member of US Postal Service pro cycling and a domestique for Lance Armstrong, Floyd had a cycling accident, suffered a hip fracture and underwent surgical pinning of the hip. It worked relatively well for a while but following the 2006 Tour de France, where Lloyd brought home the Maillot Jaune signifying the winner of the great stage race, he had an operation on the hip akin to replacement called resurfacing. The socket of the joint is replaced with a metal cup and the head with a metal ball. It's an operation performed on the young, active population with end stage arthritis of the joint. Floyd is out there riding with the best of them, but is it wise. History would tell us no.

In a recent edition of the Journal of Bone and Joint Surgery, Harlan Amstutz, M.D. reported on an investigation at the Joint Replacement Institute at Saint Vincent Medical Center, Los Angeles, California where they studied 485 patients, mean age of 48.7 years, 74% male, averaging about ten years from joint replacement. Sadly, 23 patients underwent revision (repeat hip replacement.)

The authors concluded that, "High levels of sporting activity can be detrimental to the long term success of hip resurfacing devices, independently from other risk factors. Patients seeking hip resurfacing are usually young and should limit their involvement in sports that the implant construct will be able to tolerate."

There may be some hope, however, for the athletes that come behind us. Improvements in the polyethylene liners of both hips and knees with antioxidants which seems to extend longevity.  Frequently, a complete knee replacement may not be needed.  A half knee, or unicondylar replacement may be the ticket.  For hips, "simple" resurfacing, after a very rocky resurgence including metal-on-metal hip law suits and personal injury, several orthopedic surgeons like Tom Gross, MD in Columbia, SC have done thousands of resurfacings, many in runners, and may be the pathway to the future.

In other words, if you have the joint resurfaced/ replaced, your racing days will likely come to a close. That said, being a race volunteer is fun and rewarding. Many of us have already found that out.  To further quote Dr. Amstutz "...both patients and surgeons should be aware of the fact that high-demand activities performed frequently are associated with reduced survivorship over time, and patients should be properly counseled  with respect to high levels of sporting activity on the basis of the presence of additional risk factors."  But as technology marches on, this will not always be the case, I'm certain of it.

Image, Google Images.

* Post race it was found that Floyd had some problems with his testosterone to epitestosterone ratio in a number of samples.  It was triple the WADA limit.

Sunday, January 11, 2015

Faster in 2015

It's January for Pete's sake!  You can be better, you can be faster, you WILL be faster in 2015!  You have months to get there. 

Brady performs at a high level because he accepts nothing less of himself. Ask the Ravens!

 Dinner with God

(This is not new, but given the time of year, I thought it appropriate.)

 God is eating dinner alone.

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

 Peyton Manning walks up and God says what do you believe?
Manning says, "I believe in your total goodness, generosity, and that you have given all to mankind."
God is greatly moved by Manning's eloquence and offers him a seat to his right.

 Finally, Tom Brady comes to the table, God asks, "And Tom, what do you believe?

Brady replies, "I believe you're in my seat."


 "Lack of planning on your part does not constitute an emergency on mine."

 What did you forget? And don't say nothing. At one point we've all omitted one thing or another. In a previous blog, I somewhat sheepishly admitted leaving my bike shoes home for one of my "A" races, an event in which I'd won the age group the year before. Needless to say I did not repeat!

 This is the time of year that the conscientious triathlete not only begins to dream of the potential for the upcoming racing season but starts to develop a series of goals and a road map to get there. This could be something as complete as a computer generated Annual Training Plan where the entire schedule, division of swims, bikes, runs, rest days, the works, are populated. Or, it could be sitting down with the local swimming guru if this is your weakest sport, your limiter so to speak, and getting his/her hands on expertise at incorporating the best combination of workouts, drills, indoor and outdoor swims to put you at the greatest advantage come race day. It also wouldn't be out of the question to plan that single sport block that we've discussed before.  It's a unit of time, early in the season, where an inordinate amount of training - but not so much that it leads to injury - is devoted to one of the three sports. Swimming seems to get the most attention.

 Since this blog is about minimizing injury, this time of year would also be ideal to plan ones training stress, training volume - the amount of work you plan. This is the slope of the effort line from now till the first race that not only gets you prepared, it does so in a very gradually increasing fashion, to minimize the potential for Achilles tendinitis, IT band problems, stress fractures, etc.

 I firmly believe that much of the misery, lost training time, races missed, etc. could be avoided if each athlete took the time to plot out the whole year, just as Mark Allen preaches, with this in mind. It would sure make my work load easier, and life happier for many.  

In other words, I'm not going to be a "too much too soon"athlete at the medical clinic in 2015.

 It's January for Pete's sake. If you haven't finished your Annual Training plan, do it today.

Wednesday, January 7, 2015

Triathletes Look and Feel Younger Than Their Peers

So often times it happens
that we live our lives in chains
and we never even know we have the key.

                                                                                The Eagles, Already Gone

             The number of candles on your birthday cake is less important all the time.

This was original published in the Harvard Health Letter and written by Heidi Godman.  It addresses exactly how many in this sport feel even if they don't want to admit it.  The choice of focused activity over inactivity does us a world of good.  Triathlon is considerably more than just a sport, it's a lifestyle choice.  Probably one that lets you live longer too!

Feeling young at heart may help you live longer

I just celebrated a birthday, and not the kind women like to crow about. Let’s just say I’m mid-century modern. But I feel as young and as vibrant as ever. I have energy, a zest for life, and a real sense of purpose. And it turns out that this youthful feeling may pay off big-time. A research letter in this week’s JAMA Internal Medicine found that older people who felt three or more years younger than their actual (chronological) age had a lower death rate compared with those who felt their age or those who felt more than one year older than their actual age.

You’re as young as you feel

Two researchers at University College London looked at the responses of about 6,500 men and women who answered the question, “How old do you feel you are?” The respondents were age 52 and older, with an average age of 65. Their answers:
  • about 70% felt three or more years younger than their actual age
  • 25% felt close to their actual age
  • 5% felt more than one year older than their actual age
What came next was the really interesting part: Eight years after study participants answered the age question, researchers determined which ones were still alive:
  • 75% of those who felt older than their age
  • 82% of those who felt their actual age
  • 86% of those who felt younger than their actual age.

More than just a state of mind?

Did a youthful feeling keep people alive? There was no association between self-perceived age and cancer death. But researchers did find that the relationship between self-perceived age and cardiovascular death was strong. They speculate that feeling younger may lead to better health habits. “Feeling younger or older itself seems to have an effect on our health,” says Dr. Ronald D. Siegel, assistant professor of psychology, part time, at Harvard Medical School.
He says there are several ways that feeling younger psychologically might lead to better health. One is exercise. Good health is associated with 150 minutes of moderate-intensity physical activity each week. “When people see themselves as old, they’re more likely to abandon physical challenges which feel difficult, such as, ‘I don’t think I should ski any more, I’m an old man.’ When people feel younger psychologically, even if physical exercise is challenging, they’re more likely to pursue it, believing no pain no gain,” Dr. Siegel explains.
Another way that feeling younger leads to better health may be attitude about diet. “If we feel old, we’re likely to treat food with an ‘I won’t live much longer, I might as well enjoy this’ attitude which could lead us to eat unhealthfully. If we feel young, we may have more of a future-orientation that will lead us to eat with future health in mind.” Avoiding added sugars, trans fats and saturated fats, and increasing dietary fiber, good fats, whole grains, and omega 3 fatty acids is important for good health.

Grow younger each day

Feeling younger may also inspire a sense of resilience that keeps people young. Don’t worry if you’re not feeling especially bouncy, says Dr. Siegel, who’s also the faculty editor of Positive Psychology, a Special Health Report from Harvard Medical School. He has plenty of suggestions for helping us reach a younger state of mind:
  • Challenge yourself to try new things, learn new ideas, and develop new skills. Realizing that most human abilities follow a “use it or lose it” pattern can motivate us to stay active in all realms of our lives.
  • Bring your attention repeatedly to the present moment, through formal mindfulness meditation or informal mindfulness practice. It can help you to appreciate this moment, rather than becoming lost in regrets about the past or imagining future deterioration.
  • Develop a sense of meaning in life. Focus on something larger than yourself, whether that’s connecting with people close to you or helping improve the lives of others. Or commit yourself to a hobby you love, such as gardening, attending the theater, dancing, or reading. “When our focus is just on our own immediate pleasure or pain, we’re much more likely to have difficulty with the aging process,” says Dr. Siegel.
Personally, I’m going to celebrate my new year by doing more bike riding with my husband and our youngest son; more lunching, shopping, and gabbing with our teenaged daughter; and more philosophizing with our oldest son, the economics guru who’s about to graduate from college. I may be a little older, but I don’t feel older. And I hope I can stay young at heart, no matter how many candles are on my cake!