Monday, August 29, 2016

Calf Strains

"I intend to live forever.  So far, so good."
                         Richard Wright

You never know how things will end up.  Recently I was listening to my wife and a high school classmate talk about  HS dances growing up in the western suburbs of Chicago and the great music they had.  As I remember mine, often times the band were classmates just figuring out how to play the guitar or drums doing a wretched cover of a popular song of the day.  The ladies countered with, "Oh no, we had this terrific band, ultimately famous, playing the high school and college circuit back them."  Who would this talented group become?  STYX.

So, you never know now where you or your buddies will end up. Work hard and pay attention!  Maybe you too could be #1 on Billboards top 100.  Or a great triathlete.  Or both.


Aside from being well dressed local business men, what do these two Ironman Finishers have in common?
Ironman finisher Pat McCann
Ironman finisher Mike Hemenway

  They are both have suffered from a calf strain.  In what's become an all too common story, both of these superb athletes have moved away from triathlon because of injury but stay active in other endeavors.  Pat trains daily with the area SEAL Team Training - yep, you've seen them in the park, lots of push ups and carrying logs around, you know the type (my type actually; so do I).  Mike has had a hip replacement and so his options are a bit more limited.  He bikes, walks and although he goes to the pool and says he's swimming, I'll bet he spends more time talking to the life guards.

Successful, continuous running is all about balance. Only part of this, regardless of body habitus,  is the ability to glide down the track while others lunge, lurch or plod.  Paul Jagasich, a professor of modern languages at Hampden-Sydney College in Virginia, calls this working with the elements.  He successfully swam the English Channel in 1988 but had a very hard go of it somewhere near the middle because of the waves and rough seas.  He was struggling mightily with his environment...until he figured out the timing of the waves and how to stroke from wave top to wave top.  It was "dancing on the waves" as he later put it. It's applicable to your running as well.

As runners, if our brains are constantly in gear considering our running surface, footwear, environmental factors, previous running load/stress/effort, then hopefully we'll minimize the potential for injury.  In Born To Run, Christopher McDougall quotes the Sports Injury Bulletin, "Athletes whose sport involves running put enormous strain on their legs." The American Academy of Orthopedic Surgeons (of which I am a member) concluded that distance running is "an outrageous threat to the integrity of the knee."  In other words, we as triathletes need to be on top of this every day so that we're concentrating on our running successes, not visits to Physical Therapy as we make our daily log book entry.  We'll work with our elements.

Lets look at the pertinent anatomy of the calf.

The two main lower leg posterior muscles are the gastrocnemius, or gastrocs, and the soleus.  More superficial, the gastroc crosses both the knee and the ankle joints and aids in both knee flexion and ankle extension - toe down. The soleus is deeper and contributes to your ability to stand on your toes.

When evaluating the patient with calf soreness, some will report the acute onset of pain near the center of the calf, "Like I got hit there with a golf ball!"  Interestingly, others experience no sudden pain, only a localized soreness following exercise.  Rarely they can remember over stretching the muscles.  In the pre MRI days, this would have been classified as an injury to a tiny muscle deep in the calf called plantaris.  But, we now know that the origin of pain is the medial (inside) head of the gastroc and that once noted, if the activity continues a complete tear of the muscle may follow.  The athlete should be so warned.  (Other sources of calf pain including stress fracture, blood clots, etc. should be considered.) That said, most calf strains only involve a small portion of the gastroc. 


The junction between the gastrocnemius muscles and achilles tendon

A mild strain results in only a small amount of pain and/or limitation of exercise and is called a Grade 1 strain.  Grade 2 strain injuries are more involved and may be accompanied by swelling and bruising of the calf - often quite extensively!  They will be more painful and will limit most leaping, jumping or running sports.  At this point, the care giver will likely suggest rest without sports participation until pain free.  The athlete would prefer to heal this fully the first time and not suffer a recurrence. Gentle calf stretching (not to the point of pain) and icing will be recommended.  Support hose often assists in resolution of the swelling.  Once the triathlete returns to sport, heat before participation may be beneficial.  Services of a Physical Therapist/Athletic Trainer may also speed the recovery with ultrasound and massage, and don't forget about the benefits of Ibuprofen.  Casting may play a role occasionally.

Lastly, a Grade 3 strain can include a greater involvement of the muscle to the point of rupture, an inability to walk or contract the muscles, and significant swelling/bruising.  These are frequently repaired.

Usually a Grade 1 injury resolves in 10 days, Grade 2, 4 - 6 weeks and a grade three 3-6 months.  There have been reports of some permanent weakness after these.  Fortunately, the Grade 1's and 2's are the most common.

And, in the words of General Patton, "Success is how high you bounce when you hit the bottom."  I suspect that this can be said about more than triathlon.

Monday, August 22, 2016

Alcohol in Triathlon. How Much is Too Much?

At one point, I held the record for longest time between 1st and 2nd Hawaii Ironman's.  I'm quite sure it's been broken since. 1982-97. Like Mike Reilly observed, like the  appearance of Halleys comet.  Thanks Mike.

Are you ready to drive following an injury or operation?

The following is an interesting quote from AAOSNow, 5/2015 put out by the American Academy of Orthopedic Surgeons.

"One of the most striking findings was that insurance companies and law enforcement agencies generally consider the patient to be the only person responsible for determining when he or she is fit to drive.  There is no "clearance" or "doctor's note" that can help if a patient is in an accident or receives a ticket."

How much alcohol is too much?

The thresholds for safe and healthy drinking change with age. Talk to your doctor about your limits.
No doubt you have heard that consuming alcohol in moderation—one to two drinks per day if you are a man—has been linked to better heart health. But whether an alcoholic
beverage is friendly or hostile to your well-being depends on two things: your current health status and how much you drink. A personalized approach is best.
"For some people, depending on what medications you are taking and other factors, even light drinking might not be a good thing," says Dr. Kenneth Mukamal, associate professor of medicine at Harvard-affiliated Beth Israel Deaconess Medical Center. "For other people it could plausibly be beneficial."

Moderate drinking and health

Scores of studies have examined the association between moderate drinking and health, and many find a consistent connection. Observed in large numbers over time, moderate drinkers appear to suffer fewer heart attacks and strokes, less diabetes, and stronger bones in older age, compared with people who drink lightly or not at all. In this case, "moderate" means one to two standard alcoholic drinks per day for men and one drink for women.
Does this mean moderate drinking actively improves health? We are not sure. Perhaps moderate drinkers also eat healthier foods, exercise more, and control stress better. Or, people who don't drink may be avoiding alcohol because they are in poorer health or because it interacts badly with their medications. If so, this would tend to make the moderate drinkers look healthier in comparison.
At the same time, there is no question that excessive drinking spells trouble. In men, the health effects show up as increased heart disease, stroke, and certain cancers—although part of this traces to the tendency of heavy drinkers to also be smokers.

Common medical reasons not to drink

  • If you take the blood-thinning medication warfarin (Coumadin), alcohol can trigger unwanted bleeding.
  • If you are struggling to control your blood pressure, two drinks a day could noticeably raise your numbers.
  • If you have balance problems, be cautious about how much you drink. It puts you at risk of falls.

What's safe for you?

Two drinks a day may be safe, but only for the average man. "Two drinks a day is an average distributed across the population," Dr. Mukamal says. "There are inevitably going to be people in that population for whom that is not true."
For example, some research has found that people who limit alcohol to between two and six standard drinks per week have a lower risk of cardiovascular disease than people who drink more. That averages out to less than a drink a day. In fact, the American Geriatrics Society suggests that people over 65—both men and women—should limit themselves to one daily drink. Two drinks a day might cancel the benefit, but still do no major harm.
In the end, it is not possible to offer a firm recommendation because of scientific uncertainties and individual differences in background risk for chronic disease. Dr. Mukamal suggests a "personalized medicine" approach. The assessment starts with a conversation with your doctor about whether moderate drinking is safe and prudent for you. "That's a question well worth asking your physician," he says.
Of course, if you don't drink, don't start in hopes of helping your health. Instead, get regular exercise, eat a healthy diet, and of course don't smoke. These steps will enhance virtually every aspect of your health, from overall mood to sexual potency.
"For people who don't drink at all, the consistent message is don't start," Dr. Mukamal says. "There are so many other ways to make your health better that don't raise the complicated issues that alcohol does."

What is a standard alcoholic drink?

Some alcoholic drinks contain more alcohol than others. As with all matters nutritional, you need to consider the portion size. For
example, some cocktails may contain an alcohol "dose" equivalent
to three standard drinks.

Sunday, August 14, 2016

Plea For Thinking about hydration, not reacting to what you read

Losing is Good For You

As children return to school this fall and sign up for a new year's worth of extracurricular activities, parents should keep one question in mind.  Whether your kid loves Little League or gymnastics, ask the program organizers this: "Which kids get awards?" If the answer is "Everybody gets a trophy," find another program.* 


“Water, water, everywhere,
And all the boards did shrink;
Water, water, everywhere,
Nor any drop to drink.”

Although you learned this line in HS reading the Rime of the Ancient Mariner, written by Samuel Taylor Coleridge, who'd have thought that 20 or 30 years later it would apply to you?  The speaker is a sailor on a becalmed ship that is surrounded by salt water that he cannot drink. Perhaps the triathlete, surrounded by conflicting information understands the reference better than many.

If you're over 40 and concerned about race hydration read on. How many times have you, after a workout or race, found yourself thirsty as all get out needing hours it seems to get the tank filled back up?  Although you've calculated your sweat rate and understand current dogma that you should drink to thirst, you see it working for younger athletes, but for you, not so well.  Here's why.

Everywhere you turn there seems to be "10 Rules for Hydration"  or "Must Know Hydration Tips for Triathletes" type articles.  Do them or you're guaranteed to both have GI issues and fail at your event they tell you.

Let's take a different approach, one that say comes from science, experience and the potential that there may be no one size fits all.  If we think historically as little as 10-15 years ago where then current thought revolved around cramming as much fluid in you pre-race and then keeping it that way (potentially putting the athlete at risk for EAH, Exercise Associated Hyponatremia depending on conditions and athlete body habitus.)  We were told to carry a water bottle around with us for the last hour before the race, sipping constantly to fully tank up, urinate right before the gun, and we'd have the best chance at hydration success.

But we all get dehydrated at the same rate?  Perhaps more importantly, is the definition of dehydration the same for all athletes.  I suspect not.  Take the thoughts of two highly respected voices in triathlon, super coach Joe Friel and super nutritionist Asker Jeukendrup. The latter writes passionately that as little as 2% dehydration can affect some athletes performance while Friel has preached for years that the race's victor might be the most dehydrated in the event.  Apply this to your own experience, at the pool for example.  Why is it do you suppose that the folks in lanes 1-4 have their water bottles, suck on them in between sets, but the woman in lane 5 has never brought any sort of fluid replacement and seems to just fine.  In fact, perhaps her performances are better than fine.

It's my contention that the drink to thirst camp and the drink on a schedule are both correct, but in different athletes.  Take for example two Training Bible Coaches I know.  We'll call them Jim and Joan.  Jim's a little older, understands that one's sense of thirst, the feeling that you need to drink given a certain level of water loss, tends to diminish with age, especially once you hit 40.  Jim saw 40 a good while ago.  He can tell you about ending up the med tent after a 70.3 getting not one bag of IV fluid but 2!  "You know, it just didn't cross my mind till near the end of the run I was concentrating so hard on my competition knowing I was on the bubble spot for Kona."  He's always had a fluid replacement schedule since and keeps very accurate mental notes as to how much he's consumed and how it relates to the effort and the conditions.  Joan on the other hand has no particular goal in mind, waits 10-15 minutes after bike mount before drinking per the teaching of Dave Scott, but "just drinks when my body tells me to."  She drinks to thirst as espoused by renowned Tim Noakes. 

So the take home here is to practice, practice and write it down.  See if in other races simply drinking to thirst works for you and it just might.  But if find yourself taking a good long time before you need to urinate, or you drink, drink, drink starting with the water coming from the post-race shower head, then maybe you need to at least be prepared for a minimal drinking plan and be aware of the volumes of fluid taken in.  If you have trouble remembering how much you've consumed, I've seen some athletes put 10 pieces of black electrician tape on their bike, discarding one for each full water bottle.  Or you could develop a system of your own.
KONA CONDO  We still have space in our condo race week in Kona if you or a friend are looking.

*You can read the rest of this well written piece from the NY Times by Ashley Merriman at .

Tuesday, August 2, 2016

Should Triathletes be Circumspect When Taking Antibiotics? You bet!

Triathlon brings out the best in us all

Before I did this blog a while back, I got fairly frequent questions from triathletes about the risk/benefit ratio of a certain class of drugs. "My doctor wants me to take this antibiotic but I'm not so sure," was the typical questioner.  And the concern was valid.  The reason you are seeing this again is that the FDA has recently placed its strongest warning on the box label for this product and it's one you should understand before potentially using this antibiotic.

So, first, the previous blog - it's quick - then a copy of the recent FDA warning with highlights.  At least it's not more bad news about the Olympics and the zika virus.

Antibiotics - we'll find ourselves in a real pickle if we're not careful.  As time passes, greater and greater bacterial resistance to antibiotics is developing.  Fewer and fewer new antibiotics are coming on the market.  If you were Big Pharma, given the potential of billions of dollars invested, would you want to sell a drug to lower cholesterol that once started,  a patient would take for life (generating big bucks for you and your shareholders)....or a new antibiotic they'd take short term.  You obviously see the issue here.

Several athletes have questioned the use of antibiotics lately, especially as it relates to potential complications. For this piece I interviewed pharmacists at: 1) my hospital, 2) a private drug store in the area, 3) a national chain drug store, 4) The PharmD Drug Information office at a nearby large hospital, 4) The Physician's Desk Reference (very big book), etc. to try to give the most well thought out answer.

 Before the discussion, however, we must continually remind ourselves that the days of simply going to the doctor with a problem and expecting to "Get something for it" are gone. Long gone. We as consumers are expected to understand that there are both viral and bacterial origins for a host of infections processes and that antibiotics are ineffective in cases of viral illness. The doctor is expected to know the difference. That said, on more than one occasion, I am quite guilty of giving out a prescription when I was certain that the patients problem was viral. It's what they expected and, particularly when working the ER, was the path of least resistance.

 Depending on your source, the 5 most commonly prescribed antibiotics are Amoxicillin, Augmentin, Penicillin, Zithromycin and either Cipro or Levaquin (also known as ciprofloxacin and levofloxacin). Most of the questions have centered around the last two, members of a family of drugs called fluoroquinolones. This class of broad spectrum antibiotics has been around since WWII coming originally from a drug used in malaria called Chloroquine.

 So, your physician had determined that you have a bacterial infection and needs to choose the "best" form of treatment. But the specific antibiotic chosen is a complex process taking into account the specifics of the patient and the illness, the cost of the different drugs, the insurance coverage and what out of pocket expenses will be, the dosing schedule (once a day, four times a day, etc.) and the likelihood the patient will adhere it, and...oh yeah, potential side effects. In the case of the fluoroquinolones, the potential for tendon problems is noted by the manufacturer as "Ruptures of shoulder, hand, Achilles tendon or other tendons that required surgical repair or resulted in prolonged disability have been reported.....(this risk is increased in patients taking steroids, especially the elderly.)" But simply watch any evening news TV drug ad, say for Viagra, and they quote a list as long as your arm of potential problems. I've heard that after the third one your brain shuts off. Has it stopped people from taking Viagra?

 If you go to the Peoples Pharmacy web site, there are over 100 posts from folks who report a host of problems which they attribute to Levaquin. But if you look at both the significant good that these drugs do and the enormous number of prescriptions written, the incidence of tendon concerns is pretty darn low. In fact, on Slowtwitch, Dr. Rod Roof noted that "The Achilles tendon is a bit overblown (based on the number of tendon issues vs. total prescriptions that is)" and a number of physician triathlete posters have both prescribed and personally used these medications without a downside.


Triathlete take home. Print this and save it somewhere. Next time your doc recommends an antibiotic for your bacterial infection, talk to him/her about it, particularly your knowledge and concerns. And, if after reading this you feel you'd like to stay away from this class of drugs until other options have been exhausted, say so. If you do end up on one, it would seem prudent to first ensure you're not taking a corticosteroid like Prednisone, and to back off the training for a while. In the unlikely event you should experience tendon difficulties, stop the drug and call your doctor. But, again, the incidence seems pretty low and if it were me, this is the thought process I'd use and probably take the drug.  But I'd do so from a position of strength and knowledge.


The New Warning

ISSUE: FDA approved changes to the labels of fluoroquinolone antibacterial drugs for systemic use (i.e., taken by mouth or by injection). These medicines are associated with disabling and potentially permanent side effects of the tendons, muscles, joints, nerves, and central nervous system that can occur together in the same patient. As a result, FDA revised the Boxed Warning, FDA’s strongest warning, to address these serious safety issues. In addition, FDA updated other parts of the drug label including the Warnings and Precautions and Medication Guide sections.
FDA has determined that fluoroquinolones should be reserved for use in patients who have no other treatment options for acute bacterial sinusitis, acute exacerbation of chronic bronchitis, and uncomplicated urinary tract infections because the risk of these serious side effects generally outweighs the benefits in these patients. For some serious bacterial infections the benefits of fluoroquinolones outweigh the risks, and it is appropriate for them to remain available as a therapeutic option.
FDA is continuing to assess safety issues with fluoroquinolones as part of FDA’s usual ongoing review of drugs and will update the public if additional actions are needed. See the FDA Drug Safety Communication for additional information, including a Data Summary and Additional Information for Health Care Professionals and Patients.
BACKGROUND: The labels of fluoroquinolone medicines already have a Boxed Warning for tendinitis, tendon rupture, and worsening of myasthenia gravis. The labels also include warnings about the risks of peripheral neuropathy and central nervous system effects. Other serious risks associated with fluoroquinolones are described in the labels, such as cardiac, dermatologic, and hypersensitivity reactions. After FDA’s 2013 review that led to the additional warning that peripheral neuropathy may be irreversible, FDA evaluated post-marketing reports of apparently healthy patients who experienced disabling and potentially permanent side effects involving two or more body systems after being treated with a systemic fluoroquinolone
RECOMMENDATIONPatients must contact your health care professional immediately if you experience any serious side effects while taking your fluoroquinolone medicine. Some signs and symptoms of serious side effects include unusual joint or tendon pain, muscle weakness, a “pins and needles” tingling or pricking sensation, numbness in the arms or legs, confusion, and hallucinations. Talk with your health care professional if you have any questions or concerns (see List of Serious Side Effects from Fluoroquinolones in the FDA Drug Safety Communication).
Health care professionals should not prescribe systemic fluoroquinolones to patients who have other treatment options for acute bacterial sinusitis (ABS), acute bacterial exacerbation of chronic bronchitis (ABECB), and uncomplicated urinary tract infections (UTI) because the risks outweigh the benefits in these patients. Stop fluoroquinolone treatment immediately if a patient reports serious side effects, and switch to a non-fluoroquinolone antibacterial drug to complete the patient’s treatment course.