Thursday, August 17, 2017

The Triathlete in Pain, Opioid Avoidance/ Thank God I'm Not Racing Party

     A "Thank God I'm Not Racing!" Party in Kona?  

Site of one TGINR party
Although I'm lucky enough to go to Kona every October to work the event, I've missed the past couple TGINR parties as I'm usually still on the pier getting those last minute details finished so that come the starting cannon in the morning, those competing have the best shot at success.  Plus, I'm sunburned, been sweating all day, and everybody else is clean and smells nice. Bob Babbitt is not only a great guy, but a great host at this open bar buffet. We've both been part of the event for 30+ years, and although he doesn't really know me, he couldn't have been more gracious.  Thanks Bob.

So if you find yourself on the Big Island the night before this year's World Championship, see if you can't wrangle an invite to this fun event.  And don't forget to thank Bob!

Oh, and get one of the hats.  They're terrific.  Check out Facebook TGINR 2016 for a couple pics from last year.

Might be you one day!

Ankle fracture weeks before "A" race Ironman
"Sickness will surely take the mind, where minds don't usually go.  Come on the amazing journey, and learn all you should know."
                                                             Tommy, The Who

"At some point in your triathlon life, you may have some type of injury such that you're in enough pain that some sort of pain medication is offered/requested.  So many of us are resistant to the "there's a pill for that" mentality but we're addressing situations which are out of the ordinary and by using the suggested medication, perhaps other parts of life will benefit like amount of sleep, ability to exercise, spousal relations, etc. There are many options, and if you have a general idea of what might work best for you ahead of time, then you'll be neither over nor under medicated.  Let's look at some of your choices.


Anacin, Ascriptin, acetylsalicylic acid and other forms of this work horse medication have been around for decades and have found wide acceptance as an analgesic in the treatment of minor pain.  Either alone or in combination with or substances such as narcotics, it's proven most effective.  It also finds use as an antipyretic (lowers temperature,) an anti-inflammatory agent and most recently as an anti platelet drug in the prevention of myocardial infarction's, strokes and blood clots in low doses. The author takes a daily baby aspirin (81 mg) for just such an indication.  It's primary negative is the occasional formation of GI ulcers or stomach bleeding.  It's one of the most commonly used medications world wide.


Tylenol, like aspirin, is an analgesic (diminishes pain) that's available without a prescription and is useful in treating minor pain and flu like symptoms.  It also finds it's way into combination drugs like narcotics for more severe pain such as post operative, obstetric, or in those with cancer pain. It is not an anti inflammatory and does not share the same side effects as aspirin. But, if inflammation is part of the presenting symptoms, then acetaminophen may not be the best choice. In chronic use or larger doses, it can be potentially detrimental to liver function, and is a common cause of death in those who've taken a drug overdose.  It is quite safe when used appropriately.

Non-Steroidal Anti Inflammatory Medications

The NSAIDs, Motrin (ibuprofen), Naprosyn (naproxen),Clinoril (sulindac),Celebrex (celecoxib), etc. as they are called, can be quite useful in treating chronic or arthritic type pain as well as acute pain.  Like aspirin, NSAIDs also have the ability to lower temperature.  Their primary role is in the treatment of inflammatory conditions, the -itis's, as in tendinitis, bursitis, etc.  Once again, occasional GI distress is the major potential side effect. It is reported to be less with the family of drugs like Celebrex, a COX-2 inhibitor.  As with any medication, you should take it when needed but stop when you don't.

Corticosteroids (Do not confuse with anabolic steroids)

In select circumstances, these anti inflammatory agents like prednisone, Medrol Dose Packs, etc. can be quite effective over short durations.  They are not to be confused with anabolic steroids like the weight lifters/body builders have reportedly used.  You might be given these orally or as an injection into a joint or a tendon sheath.  Side effects can be elevated blood sugar in diabetics, weight gain, and adrenal suppression. Careful here. Often used short term for allergic reactions, poison ivy and the like.


Widely prescribed by the medical system, drugs like morphine, codeine, hydrocodone,etc. find a role in controlling more severe pain.  They require special licensing from the Drug Enforcement Agency to prescribe but help patients through surgery, migraines, deliveries, trauma, etc.  They should only be taken when the above options prove ineffective.  On the downside one finds the possibility of tolerance if taken for a long time, addiction, abuse, etc. The country in the middle of an opiod epidemic as you know, and hopefully, should you need pain relief with this class of drugs, specific uses and risks are discussed with you before you fill the prescription.


 In many instances, simply starting with ice and/or heat can make a big difference.  This list of medication categories is not meant to be exhaustive.  Electric stimulation, acupuncture, massage, physical therapy, etc. all may play a role in your care and return to health.

So, depending on your situation, if in pain, and asked to consider one or more of the above options, work with your health delivery team to determine which of the above agents might be best for you, remembering that a lot of pain is probably not OK, a little pain could be.

Sunday, August 6, 2017

Variety, It's the Spice of Triathlon Training

Variety, it's the Spice of Training

Obstacle course racing.  It's great!  If you've read this blog in the past, you know I'm a champion of variety in training and racing.  Keep it fresh.  Keep the interest level high.  In my circle of training buddies, many have done a Tough Mudder (or TM half,) Rugged Maniac, Spartan or other event where getting dirty is just part of a day's work.  Er, day's fun.  That's more like it.  Most are around 2 hours or less, present a fair workout worthy of log book entry, and when done with friends are the tales that make up winter laughter.

Respect your injury.

Most triathletes are psychologically stronger than they are physically.

Many athletes focus on training related injures involves solely whether or not they’ll be affected in an upcoming race.  Little thought is given to making injury resolution priority #1.  They've sought help from a friend, an internet forum, or local medical professional. But in the end, many realize they've invested so much time and energy as part of this sport, there's a good chance they know more about themselves athletically than any physician.  Although this is likely not true medically, this gives them an insight into helping their care giver help them. It's a pretty unique patient-doctor relationship that as a physician I don't see all that often but one I enjoy.

Brett Sutton, famed tri coach, views it this way: "injuries are nothing more than a test of character.  You see quickly how they deal with adversity.  Injuries go but the scars remain in the minds of most." (Sutton's comments leave me wondering if those are positive or negative scars.)

The take home message here is that we will all be injured at one point or another, some of us frequently, some of us annually, some less.  You know that all of us get a great deal more out of of triathlon than finish line times.  Although you've heard this before, you can't hear it often enough.  Listen to your body.  Most triathletes are stronger psychologically than physically!  Really.  And I think you know it.  (For those of you old enough, does the name Gordon Liddy, organizer of the Watergate burglaries during the Nixon administration, mean anything?)  If we have the potential to do things to ourselves in the name of fitness, we have the potential to undo them as well.

Monday is the "most commonly injured" day.  It's not actually. It's just the day that people complain of pain the most. "I don't understand it. I just ran my usual 5 miles this morning."  What they don't see is that it may have taken a couple days for the effects from Saturday's big brick workout to become apparent.  I see it all the time.

  Take local athlete Mark Foley.  He is a master at achieving a sense of balance between offspring, job, triathlon and just plain enjoying living that many strive for but few of us achieve. You know how when you're talking with one of your tri friends, (or perhaps someone talking to you? Am I getting warm here?) and it becomes obvious that your idle chatter is cutting into their work out time? And they start to fidget? And then fidget a little more? And if you talk to them too much- "well, my T1 split at his race was 2:33 but at the next one it was..." they go into a full grand mal seizure? Yeah, I thought you did. It reminds me of one of those Whack-A-Mole games.........

Mark doesn't do that, ever. He has this sense of calmness, of control, that everything's going to be OK.  I think this is because he sees triathlon as a part of life, but not life itself.  Like many successful athletes, he's learned to utilize the darkness.  He plans work outs around work and life instead of the opposite, even if this means getting that morning work out done before heading to the lab, it gets done. Achieving this morning competence can be quite valuable since when you're the first one up, you can get in a run and wave to the deer and the newspaper guy.  Or, some time on the trainer with Phil Liggett and Paul Sherwin distracting you with previous TdF dvds.  My swim group meets at 5:30.  In short, you can get in some quality training and be done when others are just stirring.

I had someone tell me once that they'd think twice before hiring some one deeply involved in this sport.  Sure, the old adage about giving something you want done to the busiest person you know is part of this but do they think, plan, drown in triathlon during their work day to the point that it diminishes their effectiveness....

I, as anticipated, disagreed strongly knowing that a triathlete is a master of the clock.  To quote my fellow writer Lisa Dolbear when asked about time management:

"I could do a tri, I just don't have the time."
News flash: We don't have the time either, but we've found a way to carve it out of our busy lives because that's what you do when you commit to something important to you. Thirty-five year old mother of two, part-time MBA student, community volunteer, fitness instructor and full-time marketing professional Darcy DiBiase is no stranger to busy schedules. She’s also no stranger to triathlon. "I learned how to own my world at 5:30 a.m., and use the time before everyone else’s day started to do things for myself," the three-time Iron Girl finisher says. "And time is only one of the resources I needed to be successful—I’ve also found the right people along the way to keep me motivated and committed to my goals."

That's right gang, like Darcy, stay committed to your goals!

Tuesday, August 1, 2017

Thinking About an Ironman Tattoo? This May Help

Did you know that the marathon part of the Hawaii Ironman is a Boston Marathon qualifier? I think it became so about 11 years ago.  Pretty hard way to qualify for the famed Boston race.

Here are some photos I took (as you can likely tell) of how others have expressed their IM-ness through body art.

Sunday, July 23, 2017

Broken Foot 5 Weeks Before Kona; He Still Crosses the Line

Kona Snapshot: Brett Kruse

A last-minute twisted ankle isn't going to keep this Legacy athlete from toeing the line at the race of his life.

by John Post, MD

Put your feet in this athlete’s shoes for a moment. You’ve been a triathlete for 16 years, finished countless short-course events, 13 IRONMAN races, and you can’t believe your good fortune: you finally earn a Legacy slot to the 2016 World Championship in Kona, Hawaii. Life is good, just like the T-shirt says, right?

Not so fast. On a morning training run four weeks before you’re scheduled to board the 757 for the Big Island and this much ballyhooed race, you take a slight misstep going up a curb on a route you’ve done 1000 times before, and CRACK!  You twist your ankle and this awful popping sound comes from it. There's real pain, unlike simple sprains you’ve encountered before. Your first thought is whether or not you've jeopardized your performance in Kona.

In the next frame you’re in the ER. After your X-ray, the smiling doctor comes in with the good news—from his perspective: "It’s a clean break, should be healed in six weeks and you’ll be good as new. No surgery needed." That's it, no Kona. "Maybe you can just pick another race," the optimistic doctor says. What? Pick another race? There is no other race!  October 8th is the pinnacle of my athletic life. No Kona. Tears of disappointment rain down. 
This all happened to 39-year-old Seattle resident Brett Kruse, a human resources director for Starbucks. Fast forward three weeks. You’ve had great medical care by a sports minded Orthopedic team. Maybe there’s a chance. Kruse points out that "doctors speak in averages, but have little experience with the level of motivation of the IRONMAN athlete!" Amen, brother.

Broken foot or no broken foot, Kruse, a father of two, has decided to start the race. As for his prospects for success, he confesses that it may take a miracle. But if not, he says he'd prefer to give it his all until the final hour and then live with the result. "Both scenarios are better than sitting on the couch being bitter," he says.
Kruse is doing his part to follow his doctor’s orders to keep the foot immobile when he swims by donning an old bike shoe covered with bubble wrap for flotation, and as a deterrent to kicking. He’s heard that a woman from Alaska did the whole Kona run course in a fracture boot a couple years ago, but if possible, he’d like to be back in his regular shoes exiting T2 on race day.

Kruse's plan is for longevity in the sport is not necessarily speed. It’s easy to see why he loves the balance of triathlon’s three sports. A sub 10-hour finisher at one point, he would be the first to admit that he actually loves the sport. He uses the term love more than once when discussing racing and training—the perfect fit for a guy who loves being outside and says that over 90 percent of his training is on the road or in the open water. (He has a multi-day bike event in Glacier already scheduled following Kona.)

One highlight of Kruse's long triathlon career is the pride he takes in the number of friends and college mates he’s brought into the sport. When a college acquaintance would suggest poker night or a couple of beers at the local pub, Kruse just convinced them that it would be more fun to meet for a swim. He says this has provided him a social life as well as adventure and enjoyment. We would do well to emulate his seemingly effortless ability to splice training into his and his family's life. It allows him to flow with the sport instead of attacking it.
This commitment to swim, bike, and run will obviously extend past his trip to Hawaii. "IRONMAN has taught me a lot, but I feel that the biggest lesson is now just days away," he says.

So how'd he do?  Brett had a rough race, but it wasn't what you'd think.  After a stellar 1:03 swim and 5:48 bike, being careful not to stomp on the pedals, his foot performed admirably well.  But like so many of us, his GI tract shut down leading the inability to keep anything down accompanied by pretty significant abdominal pain.  As you've read so far, this guy is a trooper, and one who, like Crocodile Dundee, "thinks his way through" problems.  Brett figured out small solutions to big problems and was eventually able to run/walk his way to a 7:53 marathon.  (Just writing about it hurts,right?)  He crossed the line in 15:02, his 14th - and arguably most difficult IRONMAN - finish to the cheers and admiration of waiting family.  Nice work, Brett, we're proud of you!  Really proud. Great work.

Kruse's longevity tips
Beyond the clock: "Be realistic with family and work. Few of us get paid to do this and it would be stupid to risk your career or family stability for a race time."

From the heart: "Celebrate the process. Great race results will happen on occasion when you manage all the variables in your control and you get lucky with the rest. Focus on quality habits, love of the process, and keep a positive mindset regardless of what happens. Then be at peace with the results."

Metrics that matter: "I only get 10 or so hours of training each week, 15 occasionally. I get most of my training done in non-family time, working out with friends whenever possible."  IRONMA

This is a re-issue of an article first posted on

Monday, July 17, 2017

Considering PRP (Platelet Rich Plasma) or Stem Cell Injection?

Some days, swim practice just seems too hard; that you'd rather be on this side of the pool with your seahorse life ring. It does get better though.

Stem Cells and Platelet Rich Plasma

Whether or not the current enthusiasm shown by some in the emerging biologic choices in the treatment of musculoskeletal injuries, arthritis and the like is justified is really not yet clear. I'm speaking predominantly of PRP, platelet rich plasma and MSC, mesenchymal stem cells.  According to the Mayo Clinic, "over 600 stem cell clinics in the US offer one form of stem cell therapy or another, to an estimated 100,000-plus patients who pay thousands of dollars out of pocket, for the treatment, which has not undergone demanding clinical study."

I must say it's an attractive concept though, to use these, non-operative, in-office, minimally painful, almost sexy procedures to, as the web ads would have you believe to:

"Get you back to doing the things you love, faster and without surgery,"or

"combine proprietary biologic cellular therapies with state-of-the-art orthopedic interventions to postpone or eliminate the need for surgery," or

"If you've encountered an injury to the knee meniscus, cartilage, ACL or MCL ligaments, or have chronic knee pain due a past injury or arthritis, you may be a good candidate for knee stem cell therapy or platelet rich plasma procedures."

And then they show you pictures of people who are younger than you, possibly more athletic than you, certainly have a better golf handicap than you and more closely resemble movie stars than you, who are having this same treatment.

Too good to be true?  Probably.  If you're a regular reader of this blog, you know that I'm a fan of Paul Offit, MD, the chief of the Division of Infectious Diseases (a big deal!) at Children's Hospital of Philadelphia, and have used this quote previously.  This just seemed to be a perfect place for it.   He wrote about whether or not health food stores, wonderlands of promise, who sell 54,000 kinds of supplements, do what they say they will noting that if people want to burn fat, detoxify livers, shrink prostates, avoid colds, stimulate brains, boost energy, prevent cancer, extend lives, enliven sex, "all they have to do is walk in."

But those of us who suffer pain or distress from tendonitis, arthritis, or any number of   musculoskeletal maladies which seem incurable at the time, are a susceptible audience. The idea that these treatments can put us back on the road or in the pool are terribly attractive, right?

One of the big problems so far is that although there are a "prodigious number of clinical trials" in the literature where a host of different conditions have been addressed with PRP or MSC, according to Iain R. Murray in the prime journal of the orthopedic community, the Journal of Bone and Joint Surgery.  Those published to date "have failed to include sufficient experimental detail" to make replication by others possible.  These are complex procedures with a wide variety of "preparation methods, protocols and methods of delivery."  After an extensive period of research, and several rounds of surveys, 24 experts in the field established a consensus statement and a 23 item checklist for PRP, and a 25 item check list for those wishing to publish their results on treating patients with MSC.

What does this mean to you?  Well first off, this is an area of treatment with tremendous possibilities but there is still much to learn.  We as a medical community need to standardize and optimize our understanding of the biology of both the disease and the treatment. This is due in part from a study in the American Journal of Sports Medicine where arthritic participants were injected in both knees, one with MSC and one with just plain saline, but neither they nor the doctor knew which was which.  They had "dramatic improvement" in both knees.  So does that mean you can inject basically whatever you feel like into an arthritic knee and it will improve?  Obviously we have much to learn.  They were able to conclude from the study that the procedure was safe but that further research is necessary, following the checklists above, before the procedure is deemed effective and becomes adopted nationwide and employed in a routine fashion.  That said, as noted above, there are 100's of clinics standing by to accept your payment for a treatment tomorrow.

Sunday, July 9, 2017

Making Success Out of Your Failures (non successes?)

First, a little triathlon humor.


What are you doing?

Just wondering, who's the best?

We all fail at one point or another.  We almost all DNF at one point or another.  We almost all DNF at something really important at one point or another.  Put me right in the center of that group as well.  What, my DNF?  When was it?  The down-the-street 5K?  Nope.  The local big deal Ten miler?  Nope.  I "did not finish" a little event they have every April in Massachusetts known as the Boston Marathon.

It was hot that day along the Hopkinton to Boston 26.2 mile course, record hot weather type thing, but I've been racing for a lot of years and should have known better.  But I didn't.  I got to about 20 miles going up famed Heartbreak Hill when I was hit by a train.  The train known as massive dehydration.  It was sit down or fall down time.  And here's where I blew it. 

Instead just sitting down, resting, slowly sipping as much water or Gatorade as it took, and then proceeding down Boylston Street to my triumphant finish, I saw the bus which could take me to the finish with the other soon to be DNFers, parked at this particular aid station. I'm certain now that it's presence was complete coincidence.  So I put my brain in the off position, and got on the bus.  That was fifteen years ago.  How many times do think I've regretted that decision since?

BUT.  Fast forward to 2005 and I'm on the bike on the Big Island of Hawaii in the Ironman World Championship.  It's hot there too, right.  So around the 90 mile mark of the bike, despite best efforts to stay up with my hydration plan, my stomach just didn't want any more. I see you've been there.  I started to get dizzy.  Then really dizzy.  Just like Boston years earlier, it was get off the bike or fall off time.  But here's where the story changes.  Having screwed up Boston, I stumbled into the aid station where a very kind nurse named Alice was positioned.  We sat, and sipped, and talked, and sipped, and felt better, and sipped, until the tank was full again.  I gave her big hug, got back on the Queen Ka'ahumanu Highway and finished the bike.  OK, so it was a 7:37.  And my run sucked too at 6 hours.  But you know what?  My big shiny finisher's medal from Hawaii 2005 looks right good  on the wall over there.

The point of all this is that we all have bad days, but that some day, maybe not for many years, that bad day will fuel you to great day.  A really great day!

Oh, and Alice?  I bought her a dozen roses, drove up to the Kona hospital operating room, waited for her to finish her work, and gave them to her.  Nice lady.

Local Swimmers have a good day at the races!

Monday, July 3, 2017

We SwimBikeRun to Stay Young, We just Don't Know It

When you're out running on a road with traffic, you need to be one step ahead of the drivers. Same goes for the bike.


"Thus, it is fair to conclude that the balance of evidence suggests that caffeine withdrawal to get a better effect of caffeine is a myth. The recommendation from us is therefore to maintain your normal caffeine consumption during the preparation for your competition. You will still be able to benefit from the effects of caffeine in competition, and you will avoid any possible withdrawal 
symptoms in the days before."

We've talked about this before.  The fact that our sport just seems to keep it's participants young.  Not only younger looking, but younger feeling, and maybe just a little more agile than non-tri peers.   The article below was written by Gretchen Reynolds of the NYT and explains a portion of this.

Running {triathlon} may reverse aging in certain ways while walking does not, a noteworthy new study of active older people finds. The findings raise interesting questions about whether most of us need to pick up the pace of our workouts in order to gain the greatest benefit.
Walking is excellent exercise. No one disputes that idea. Older people who walk typically have a lower incidence of obesity, arthritis, heart disease and diabetes, and longer lifespans than people who are sedentary. For many years, in fact, physicians and scientists have used how far and fast someone can walk as a marker of health as people age.
But researchers and older people themselves also have noted that walking ability tends to decline with age. Older people whose primary exercise is walking often start walking more slowly and with greater difficulty as the years pass, fatiguing more easily.
Many of us probably would assume that this physical slowing is inevitable. And in past studies of aging walkers, physiologists have found that, almost invariably, their walking economy declines over time. That is, they begin using more energy with each step, which makes moving harder and more tiring.
But researchers at the University of Colorado in Boulder and Humboldt State University in Arcata, Calif., began to wonder whether this slow decay of older people’s physical ease really is inexorable or if it might be slowed or reversed by other types of exercise and, in particular, by running.
Happily, Boulder has an unusually large population of highly active older people, so the scientists did not lack for potential research subjects. Putting the word out at gyms and among running and walking groups, they soon recruited 30 men and women in their mid- to late-60s or early 70s.
Fifteen of these volunteers walked at least three times a week for 30 minutes or more. The other 15 ran at least three times a week, again for 30 minutes or more. The runners’ pace varied, but most moved at a gentle jogging speed.
The scientists gathered all of the volunteers at the University of Colorado’s Locomotion Laboratory and had each runner and walker complete three brief sessions of walking at three different, steadily increasing speeds on specially equipped treadmills. The treadmills were designed to measure how the volunteers’ feet hit the ground, in order to assess their biomechanics.
The volunteers also wore masks that measured their oxygen intake, data that the researchers used to determine their basic walking economy.
As it turned out, the runners were better, more efficient walkers than the walkers. They required less energy to move at the same pace as the volunteers who only walked regularly.
In fact, when the researchers compared their older runners’ walking efficiency to that of young people, which had been measured in earlier experiments at the same lab, they found that 70-year-old runners had about the same walking efficiency as your typical sedentary college student. Old runners, it appeared, could walk with the pep of young people.
Older walkers, on the other hand, had about the same walking economy as people of the same age who were sedentary. In effect, walking did not prevent people from losing their ability to walk with ease.
More surprising to the researchers, the biomechanics of the runners and the walkers during walking were almost identical. Runners did not walk differently than regular walkers, in terms of how many steps they took or the length of their strides or other measures of the mechanics of their walking.
But something was different.
The researchers speculate that this difference resides deep within their volunteers’ muscle cells. Intense or prolonged aerobic exercise, such as running, is known to increase the number of mitochondria within muscle cells, said Justus Ortega, now an associate professor of kinesiology at Humboldt University, who led the study. Mitochondria help to provide energy for these cells. So more mitochondria allow people to move for longer periods of time with less effort, he said.
Runners also may have better coordination between their muscles than walkers do, Dr. Ortega said, meaning that fewer muscles need to contract during movement, resulting in less energy being used.
But whatever the reason, running definitely mitigated the otherwise substantial decline in walking economy that seems to occur with age, he said, a result that has implications beyond the physiology lab. If moving feels easier, he said, people tend to do more of it, improving their health and enhancing their lives in the process.
The good news for people who don’t currently run is that you may be able to start at any age and still benefit, Dr. Ortega said. “Quite a few of our volunteers hadn’t take up running until they were in their 60s,” he said.
And running itself may not even be needed. Any physically taxing activity likely would make you a more efficient physical machine, Dr. Ortega said. So maybe consider speeding up for a minute or so during your next walk, until your heart pounds and you pant a bit; ease off; then again pick up the pace. You will shave time from your walk and potentially decades from your body’s biological age.