Monday, June 20, 2016

Why Would You Wear a Camelback in a Race?

At the 20 mile mark of this weekend's local marathon

I don't get it. Why, with aid stations every two miles, would you wear a supplemental drinking device that adds weight?

I went to the local marathon Saturday. I really felt for the athletes.  Watching the start (at 67 degrees unfortunately) and people clad in any number of different attires.  Many had some form of long sleeve garment, even a sweatshirt or two, based on the weather prediction of 60 at the start and a high of 74.  "Good thing they're calling for 74 today 'cause it'll be 85 tomorrow."

Ah, but the weatherman was wrong, and tomorrow came a day early.  It heated up quickly such that the race course looked like one big Good Will shop, just spread out a bit.  There were hundreds, maybe thousands of discarded clothing items on the side of the road starting bout mile 3, and among them, many supplemental drinking systems.  I imagine the racer remembered where he/she left it and planned to return and get it after the event. 

But there's an unneeded step in an already very long day for many.  My point here is that although many racers were first timers, and correctly they did what worked for them in training, this was one of those instances when simply asking a veteran who'd run this type of event before what they recommended, and would have saved them this step.  A marathon is hard enough already.  Now sunburned, exhausted, and maybe even coming from the opposite side of town, these racers have to go back out and retrieve something valuable.

This brings me to the larger issue of homework.  Race homework.  So many events have huge expos these days that the newer to the sport can find someone, maybe even one of the sales people in the expo with years of running under his/her belt.  Preferably, lessons like this have been learned in that local 5k or sprint tri.  Go to any book store for reading advice.  Joe Friel's Training Bible series or his very popular Your First Triathlon can ready even the most recalcitrant of us.  In short, do your best to have race questions answered before you leave home on race day.

Monday, June 6, 2016

1 in 2 of You Will Crash Some Day; Over 40% Kona Racers Needed Med Attn/Surgery At Some Point in Their Career

George Patton and I share the same birthday.

 "A man must know his destiny. if he does not recognize it, then he is lost. By this I mean, once, twice, or at the very most, three times, fate will reach out and tap a man on the shoulder. If he has the imagination, he will turn around and fate will point out to him what fork in the road he should take.  If he has the guts, he will take it."   George Patton

 Maybe something to think about right before the gun in your next race.  Put it on a scrap of paper. Make it a quick read at the start line, then get out there and, like Patton, KICK BUTT!
Before summer open water training in a local lake, river or ocean, make sure you line up a swim buddy first.

Road Rash

"Ain't no doubt about it we were doubly blessed, 'cause we were barely 17 and barely dressed." Meat Loaf, Bat out of Hell

 Possibly without intending, Meat Loaf was describing the amount of protection one gets from cycling clothing when you hit the asphalt. Barely dressed. But, you look good doing it. Right?


This image was sent to me by a follower.  Glad it's not my elbow.  Bet you are too!  This is several days old, dry, quiet looking, but that hole on the right side could still be, as they say on TV, "A heap of trouble!"

This injury is the result of a bike crash on to asphalt and I'll bet it hurt.   This repair was not done at the local Urgent Care but the local hospital operating room.  If, for no other reason, than to get the debris vigorously washed out of the wound.  The potential for infection is significant.

Following your bike crash, you visit your friendly local emergency room where cultures are taken from the wound (put in a cotton tip, send it to the lab to see what unexpected bacteria can be found in what should be a sterile environment). Then you're introduced to the orthopedic surgeon on call, told that your next stop is the operating room...NO, you cannot go home to let the cat out or turn off the sprinkler because you're being prepped for immediate I&D, irrigation and debridement. You meet the holding area team, the anesthesiologist, the circulating nurse for the OR as she seats you in the center of the operating table, etc. You're surprised how cold the operating table is against your naked behind! Just the first of many unfamiliar sensations.

This is all a true story. This triathlete suffered a fairly involved injury, without broken bones, to her arm above the elbow and the above sequence occurred. This picture is her arm about a week out.  She's also under the care of an Infectious Disease specialist to help manage the antibiotics as appropriate to the organisms cultured at surgery. So what are the lessons that we take away from this? Well, it's hard for many of us to get through a full season without dumping our bikes at least once - or more.  I surveyed 1600 KONA ATHLETES in 2015 and one of the questions was "Have you had a bike crash serious enough to require medical attention?  Surgery?" Almost half of the men (48%) and nearly as many women (42%) said yes.  

If we're lucky it's just a skinned knee or lateral ankle that, with a minimum of local care, heals uneventfully assuming an intact immune system. What about that dog bite? Or that more significant skin embarrassment with depth and significant bleeding?

On the road, as soon as possible following your crash (or animal bite), I'd suggest beginning by lavage (thorough wash out) of the area as best you can with the contents of your water bottle(s). I know a number of athletes who drink very little from their water bottles, particularly in cooler weather, and carry them for just such an emergency. You're prepared for a flat, loose spoke, broken chain, etc., why not be prepared for this is their motto. While you probably wouldn't use water from the creek, tap water from the nearest source, gas station, etc. to irrigate out any debris while still fresh helps a great deal. If there's any doubt, seek medical care. If the wound is over a joint or sizable, if it's at all deep, if you see a tendon, bone or joint, these are all reasons to proceed to the local medical facility right away. The longer you wait, the more time any foreign matter has to set up shop. You can also update your tetanus at that time. In fact, I know one athlete who called his docs office within minutes of an unprovoked dog bite, was told to "come now", which he did...still on his bike of course, and had the wound cleaned, tetanus administered, etc., all done in about an hour allowing him to finish his ride. Can't leave that calendar space white, even for a trip to the doctor, now can we? (See "Once a Runner,"  John L. Parker, Jr.)

For home care of road rash, shower, and although it may not be pleasant, use of a mild soap and wash cloth to get all dirt and debris out of the skin or it will be a permanent tattoo.  Try to avoid any type of strong antiseptic as they frequently do more harm than good.  After you get the wound as dry as possible, apply a very light coating of antibiotic ointment and a sterile dry gauze type dressing.  If you use the non-stick type you will be rewarded for it later.  Keep the area clean and dry until it starts to show good signs of healing and change the dressing every couple of days.  If you have doubts anywhere in the process, get medical attention. Otherwise, happy riding.

Tuesday, May 31, 2016

Racing Plan B for Triathletes- Penalties, Sizzling Heat, You Name It

Prepared For The Unexpected? At Least Thought It Out?*

Woman's unplanned visit to the "sin bin."
If you have, you'll handle the problem, as Ironman supercoach Lance Watson Preaches, "Quick, calm and organized."
Do you think, when this athlete was topping off the air in her tires this morning, that she thought, "You know, I'm sure glad I'm the the type of racer who never gets penalized..." I wonder if her race plan included preparation for this.  Does yours?

Asker Jeukendrup, Noted Sports Nutritionist, Asks, "Is gluten-free Faster?"

A study where two groups of participants, those with and those without gluten in their diets were compared.  The results showed:

There was no difference in performance between the two diets. There were also no differences in gastro-intestinal discomfort, or how the participants were feeling.  In addition, none of the markers of inflammation showed a difference between the diets.

Therefore the authors concluded that a gluten-free diet has no benefits over a gluten-containing diet in non-celiac athletes. It also had no negative effects. The authors advised that athletes seek evidence-based advice before adopting a gluten-free diet for non-clinical reasons to ensure that nutrition intake supports individualized and optimal fueling for sport performance. 

Sunday, local triathlon

They carried a man off the race course on a stretcher. I heard that he just collapsed on the run;  maybe it was the heat – a low of mid 70's last night. Plus, the sun came up well before the first athlete was body marked or the transition area opened. As the sun climbed higher in the sky pushing the mercury toward inferno status… from a racing point of view anyway, you wonder about where all these athletes were last week.  San Antonio?  Sheboygan?  Anchorage?  Cool climate or warm climate? And how much of their well planned out race plan included weather like this?  It turned out to be one of those days where the heat simply blasts you when it radiates off the asphalt. It’s a good thing most of were wearing hats and could put ice in them at the aid stations. As we watched them load the collapsed racer into the ambulance, we hoped it wasn’t something serious.

Plan “B.” Everyone needs one. You arrive at the race course and – SURPRISE – no wet suits for the swim like happened to us on Sunday in the opening outdoor 1 and 2 mile swims of the season. Or – SURPRISE – the expected temperature at race start is 15 -20 degrees higher than where you live and train. This happened at the Boston Marathon a few years ago where runners were just finishing a winter of snow running, and an unexpected heat wave brought temps in to the mid 80’s and more. Athletes were dropping like flies. There were so many people with heat related problems that the enormous armory-like building they use at the finish line with cots as far as you can see, was simply overflowing with “bodies.”

All too often, racers just plow ahead “business as usual,” and if they’re lucky, only have a poor performance. They wonder why, despite ample beverage at the post-race party and more on the way home, they still don’t pee for hours. There’s a take home lesson here.

There can be course changes, weather curve balls, rightly or wrongly you get penalized, alterations to the order of events, unintentionally getting kicked in the stomach, or face –hard- on the swim just to name a few things that cause us to re-evaluate our original race plan. How about a flat tire, broken chain or spoke, special needs bag going MIA?  If we’re to survive and do our best on that particular day, flexible we must be. Despite one’s physical suffering, always try to remind yourself that everyone in your event has the same course to ride and run on and just maybe you can do it just a little better than they do. In the immortal words of that famous rock group of the 60’s, Pacific Gas and Electric, “Are You Ready?”

Tuesday, May 24, 2016

Joint Replacement for Triathletes, Part Two, It Matters

"Not having a goal is more to be feared than not reaching one."
                                                  Chinese Proverb

Is this any truer than in triathlon where an entire year's work is frequently pointed at a single event?  This blog is part two of two where we see if replacement of a worn out, arthritic joint in a triathlete will let them "get back in the game" as we hear so often on television.

"Sure, I know several triathletes besides me who've had their knees replaced."    Chuck Graziano, Triathlete, TrainingBible Triathlon Coach            

4.5 Million Americans Living with Total Knee Replacements
TKR surgeries have more than doubled over past decade

San Francisco, CA

New research presented at the Annual Meeting of the American Academy of Orthopedic Surgeons (AAOS) found that more than 4.5 million Americans are living with a total knee replacement (TKR), as the number of TKR surgeries has more than doubled over the past decade, with the sharpest rise among younger patients. Osteoarthritis continues to be the primary reason for TKR.

Investigators used a computer model; U.S. Census data; information from the National Health Interview Survey, the Multi center Osteoarthritis Study and the Osteoarthritis Initiative; and other national data and literature to determine the number of Americans living with TKR.

The study, funded by the U.S. National Institutes of Health’s National Institute of Arthritis and Musculoskeletal and Skin Diseases, found that more than 4.5 million Americans are currently living with at least one TKR. This represents 4.7 percent of the population age 50 years or older – higher than the national rates for congestive heart failure and rheumatoid arthritis. In addition:
  • The prevalence of osteoarthritis is higher in women and so is TKR: 5.3 percent, compared to 4.1 percent in men.

  • Among persons age 60 to 69, 4.1 percent of men and 4.8 percent of women have a TKR; among those ages 70 to 79, 7.1 percent of men and 8.2 percent of women have had at least one knee replaced.
  • Ten percent of Americans age 80 and older are living with a TKR.

“The number of total knee replacements is growing drastically,” said Elena Losina, PhD, lead investigator and co-director of Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston, Mass. “We now have a lot of people living with TKR,” which may lead to substantial increases in the likelihood of revisions and complications, especially in younger patients.

Stephen Arata, PhD, at the University of Virginia preaches patience. "There are many with osteoarthritis of the knee that can put off something as complex as joint replacement if they simply step back for a moment and look at what they can do, not what they can't."  He thinks more would delay having the surgery if they could simply look at the picture of both today and well into the future.  "Many of the long term questions have yet to be answered." One definition of patience is "the capacity to endure waiting, or provocation without becoming angry or upset."  Arata's teachings are spot on for 2016.

The findings above may aide in anticipating the future challenges related to TKR, including capacity for follow-up care, health care costs, and treatment access.  Hopefully, both of us can delay a procedure such of this magnitude as long as practical.

The first triathlete I met with a total knee in place was during the marathon portion of the 1982 Ironman.  (In those days it was the Bud Light Ironman Triathlon World Championship.  It was the only one on earth.  There were 969 competitors in the race program, Scott Tinley wearing #1.  Guess what they served at the aid stations.)  Not knowing any better, I was run/walking from 13 miles on in, with two other equally spent athletes. If you've never done it, there's more time than you realize to talk with your new found friends.  For some reason, the subject of my service in Vietnam came up and one of my walking mates admitted to a gun shot wound to the knee with subsequent joint replacement.  I was flabbergasted!  I'd been taught that joint replacement was for the bocci set at the nursing home and here's this guy next to me with one...who's probably going to beat me!  Well, maybe.

As you'd suspect, I've learned of many in our sport with artificial joints since.

Sunday, May 22, 2016

Yep, Triathlon & Running, Both Bad Ideas After Joint Replacement

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

Last week, we presented a four part series on the female athlete which was quite well received.  At over 1,000 hits/day we were able to educate a good number of athletes.  This week we'll put up a two part series on what happens when the athlete, through over use (sound familiar?), trauma or just plain bad luck wears out a hip, knee, etc.  Then said athlete expects the orthopedic community of 2016 to be able to "slip a new one in there" and she'll simply get back to long bike rides on Saturdays with the girls.  Realistic?  We'll see.

"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 blogs here in the past.  The usual  take home is that life doesn't work that way. Regardless how good a surgeon or artificial joint is, it does not equal the "original equipment from the manufacturer."  

Let's see if the Orthopedic research community has refined the art of joint replacement arthroplasty to the point if, like changing a worn out tire on your car, the triathlete can have that worn out joint replaced, and return to triathlon the same athlete as before.


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 Tour de France yellow jersey in Paris, for the purposes of this discussion he makes and excellent example. Briefly, while a member of USPS 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, where Lloyd brought home the Maillot Jaune (yellow jersey) 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 frequently performed on the young, active population with end stage arthritis of the joint. Floyd is out there riding with the best of them for the time being, but is it wise. Or, more importantly, is it for you?  History would tell us no.

In a recent edition of the Journal of Bone and Joint Surgery, Harlan Amstutz, M.D., a very experienced joint replacement surgeon, 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 had already undergone revision surgery (repeat hip replacement.)

There may be some hope, however, for the athletes that come behind us. Improvements in the polyethylene liners of both hips and knees, impregnating them with antioxidants, seems to significantly extend longevity. Frequently, a complete knee replacement may not be needed.  A half knee, or unicondylar replacement may be the ticket for those athletes with wear and tear in only half of the knee, a frequent occurance.  For hips, "simple" resurfacing, after a very rocky resurgence including metal-on-metal hip law suits and personal injury claims, 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. Three local athletes, all runners, have had this operation by Dr. Gross and are back on the roads. Smiling!

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.  So if you are an athlete reading this, you are special and can't be lumped in with the Toms, Dicks and Harrys of the world. Do your homework, don't be in a rush, and you'll get what's right for you.


* Following the TdF, it was found that Floyd had some "problems" with his testosterone to epitestosterone ratio in a number of samples taken during the race.  It was triple the WADA limit!  Sorry Floyd, you're outta here!

Image, Google Images.

Friday, May 20, 2016

Special Issues in the Female Triathlete, Osteoporosis, Eating Disorders, Part Four of Four

"It's not having what you want, it's wanting what you've got"
                                                                  Sheryl Crow

Only the run to go.

First outdoor swim of the season. Today I ventured to a nearby lake to get in my first practice swim before racing starts.  If I learned nothing else, it would be to tell you to do the same.  Many lessons learned.  First, inexplicably my wet suit got a little tighter over the winter.  (How'd that happen do you think?) At about 62 F, the water was a little chilly at first, especially trying to put your face in, but that resolved quickly. Swimming straight was surprising easy so sighting went well.  Goggles didn't leak, didn't see any snakes, snapping turtles or sharks for that matter so I'm planning two more next week.  Good luck in your first dip.  Just make sure it's well in advance of your first race, you'll learn a lot.  Line up your life guard today


This is the final section of a four part series on the female athlete. We've covered some of the physical and physiologic differences between male and female athletes, injury patterns and the contributions of estrogen to ligamentous laxity.  We've also reviewed training during pregnancy.

Today the so-called female triad is considered including eating disorders, amenorrhea and osteoporosis.  I first broached eating disorders in the female triathlete in a blog I wrote for Mother's Day a while back and it has become my single most widely read blog.  Somebody out there thinks this important.

The Female Athlete Triad
Amenorrhea, disordered eating and osteoporosis define the female athlete triad. Although found at all levels and types of sports activities, the female athlete triad is more prevalent in sports emphasizing prepubertal  body type, perfection, thinness, revealing clothing and subjective judging.  These sports include dancing, cheerleading, gymnastics, figure skating and distance running.  These females tend to be in high pressure environments set up by coaches and parents.  They tend to show driven personalities.  They have poor nutrition knowledge and tend to be in families with history of eating disorders and abuse.  The earlier the diagnosis is made the more likely treatment will be successful.  Any female athlete showing one part of the triad should be evaluated for the other two parts immediately.  The true prevalence of the female athlete triad is unknown.

Disordered Eating
Disordered eating refers to a wide range of ineffective eating behaviors used to lose weight or achieve a lean appearance.  This in itself is a multifactorial problem based on issues ranging from requirements for specific sports to disturbed self image.  In non-athletes the prognosis for treating an eating disorder is poor with 50% doing well, 30% relapsing and a 10-20% mortality rate.  There are no studies specific to female athletes.

Restrictive eating behaviors such as voluntary starvation and binging-purging behaviors are only part of this problem.  Many athletes will just not eat enough to deal with energy requirements for athletic activity.  Severe caloric restriction reduces metabolic rate and causes changes in all organ systems.  Anorexia nervosa is the diagnosis when the patient views herself as overweight and restricts eating even though their weight is 15% below ideal body weight.  Amenorrhea is one of the DSM-IV criteria for this diagnosis.  Bulimia is a cycle of food restriction followed by overeating then purging.

In general eating disorders should be viewed as chronic illness with serious medical and psychological results.  Treatment requires a long term multidisciplinary approach involving physician, mental health practitioner and nutritionist.

The long recognized cessation of menses with physical training was felt to be based on low body weight and low body fat.  This is now known to be untrue.  More recent studies have shown that exercise stress and energy availability both can cause disruption of the GnRH pulse generator and the subsequent decrease in LH as a more likely source for amenorrhea.  The exercise stress hypothesis is based on high resting cortisol levels and blunted cortisol responses to exercise in amenorrheic athletes.  The low energy availability hypothesis follows studies where eumenorrheic trained women showed suppressed LH pulsatility after 3 days of training while dietary intake was reduced, but not suppressed when dietary intake was supplemented. Several other studies have supported these findings.

Amenorrhea is the easiest symptom to recognize in the female athlete triad. Exercise associated amenorrhea is a diagnosis of exclusion.  Reversal of amenorrhea is unpredictable so all women should be screened for pregnancy as part of their workup.  There is an observed decrease in bone mineral density in non-menstruating athletes which predisposes them to stress fractures and osteoporosis later in life. Calcium supplementation of at least 1500 mg a day should be encouraged in amenorrheic women.  Don't forget vitamin D but I suspect that most of you already supplement your diet with it like my physician wife and I do.  Treatment for athletic amenorrhea should begin after missing 3 consecutive menstrual cycles.  If the athlete is within 3 years of menarche, treatment should involve decreased physical training and supplemented nutrition.  If the athlete is 3 or more years post-menarche, low dose oral contraceptives should be considered.

Osteoporosis is characterized by low bone mineral density (BMD) and microarchitectual deterioration of bone tissue.  Studies confirm higher incidences of injuries and stress fractures in amenorrheic and oligomenorrheic as compared to eumenorrheic athletes.  Since the female athlete triad occurs during the most important years for women to build their maximum BMD, the question becomes whether this problem can be reversed.  Several studies do report increases in BMD in amenorrheic athletes resuming normal menses but these gains may be limited. Amenorrheic athletes using hormone replacement therapy at doses used in post-menopausal women have shown maintenance of BMD but no gains.  Weight bearing exercise has a positive effect on BMD but it is not a large increase.  The positive effects of weight bearing exercise in amenorrheic athletes are negated.  Athletes suspected of the female athlete triad should undergo DEXA scan to confirm BMD status.

Thursday, May 19, 2016

Female Triathlete and Exercise Recommendations During Pregnancy, Part Three of Four

"You got to do what you can, and let Mother Nature do the 


A great look in the Kona Underpants Run.

This is part three of four this week as we examine issues that face the female athlete.  With the summer Olympics only weeks away, and the level of complexity increased for female athletes of child bearing age secondary to the potential presence of zika virus carrying mosquitoes, it behooves us to be as knowledgeable as possible when it comes to sports and one's own pregnancy.

The Pregnant Athlete

The most important aspect of athletic participation during pregnancy is the level of physical fitness prior to conception.  The greatest concerns for activity during pregnancy include:

    Effects of elevated maternal temperature on the fetus.
  • Effect of exercise on blood flow to the fetus.
  • Effects of exercise on the weight of the fetus.
The benefits of exercise during pregnancy include weight control, improved muscle tone, self-esteem, decreased incidence of varicosities, decreased incidence of back pain and decreased incidence of sleep disturbance.  The following is a summary of the American College of Obstetrics and Gynecology guidelines for exercise and pregnancy.

Direct Contraindications to Exercise During Pregnancy

Pregnancy induced hypertension
Preterm rupture of membranes
Preterm labor during the prior or current pregnancy
Incompetent cervix/cerclage
Persistent second or third trimester bleeding
Intrauterine growth retardation

Recommendations About Exercise During Pregnancy

1.      During pregnancy, women can continue to exercise and derive health benefits even from mild-to-moderate exercise routines.  Regular exercise is preferable to intermittent activity.

2.      Women should avoid exercise in the supine position after the first trimester.  Prolonged periods of motionless standing should also be avoided.

3.      Women should be aware of the decreased oxygen available for aerobic exercise during pregnancy.  They should be encouraged to modify the intensity of their exercise according to maternal symptoms. They should stop exercising when fatigued and not exercise to exhaustion.  Weightbearing exercises may under some circumstances be continued at intensities similar to those prior to pregnancy throughout pregnancy.  Non-weightbearing exercises such as cycling or swimming will minimize the risk of injury and facilitate the continuation of exercise during pregnancy.

4.      Morphologic changes in pregnancy should serve as a relative contraindication to types of exercise in which loss of balance could be detrimental to maternal or fetal well-being.  Any type of exercise involving the potential for even mild abdominal trauma should be avoided.

5.      Pregnancy requires an additional 300 kcal/d to maintain metabolic homeostasis.  Thus, women who exercise during pregnancy should ensure an adequate diet.

6.      Pregnant women who exercise in the first trimester should augment heat dissipation by ensuring adequate hydration, appropriate clothing and optimal environmental surroundings during exercise.

7.      Many of the changes induced by pregnancy persist for 4-6 weeks post-partum so exercise routines should be resumed gradually based on a woman’s physical capability.

In conclusion, the need for the physician to understand the unique aspects in treating female athletes is paramount.  Adding these insights to primary care will only improve diagnostic and treatment efficiency.  Certainly further research is needed to better understand increased knee injury incidence in females compared to males.  Also the observant eye for diagnosing the female athlete triad is the first step to initiating early and more successful treatment in a syndrome where the patient and those around her are prone to avoidance and denial.  As a physician, guiding exercise and athletic activity through all ages and even during pregnancy of your female patients will be rewarding to your practice and empowering to your patients.

Recommended reading:

American College of Sports Medicine Position Stand on The Female Athlete Triad
Ireland, Mary Lloyd and Ott, Susan M. Special concerns of the female athlete.  Clinics in Sports Medicine 23 (2004) 281-298.
Exercise During Pregnancy and the Postpartum Period. ACOG Technical Bulletin 189.  WashingtonDCAmerican College of Obstetricians and Gynecologists; 1994

Again, great thanks to Bill Vollmar, MD and his presentation of this material in Kona at the Primary Care Sports Medicine Update