Sunday, April 20, 2014

Bunions - Bike and Running Shoes

"And be careful of what you do 'cause the lie becomes the truth."

                                                                                        Michael Jackson - Billie Jean

The Navy SEALs say, "If you cheat yourself, who won't you cheat?"  I think in triathlon it means that if your swim workout is 2350 yards, that's what goes into your logbook or is reported to a coach, not 2500.  This would be important next year if you are trying to figure out what worked in your training plan, or maybe more importantly, what didn't.

 SPOT - Ever run alone in the woods or mountains?  Ever think, just for a minute, "What if I get lost or injured, what do I do?"  Our son Chris Post hiked the High Sierra Trail and climbed Mt. Whitney solo last Spring.  This device proved invaluable as we were able to track his progress....or sometimes lack thereof....when he encountered a bear or two. If he'd really gotten into trouble, SPOT can send a 911 signal that you need help to an overhead satellite. .

Your friend in the mountains or woods.

If the joint that connects your big toe to your foot has a swollen, sore bump, you may have a bunion.
More than half the women in America have bunions, a common deformity often blamed on wearing tight, narrow shoes, and high heels. Bunions may occur in families, but many are from wearing tight shoes. Nine out of ten bunions happen to women. Nine out of ten women wear shoes that are too small.
Too-tight shoes can also cause other disabling foot problems like corns, calluses and hammertoes.
With a bunion, the base of your big toe (metatarsophalangeal joint) gets larger and sticks out. The skin over it may be red and tender. Wearing any type of shoe may be painful. This joint flexes with every step you take. The bigger your bunion gets, the more it hurts to walk. Bursitis may set in. Your big toe may angle toward your second toe, or even move all the way under it. The skin on the bottom of your foot may become thicker and painful. Pressure from your big toe may force your second toe out of alignment, sometimes overlapping your third toe. An advanced bunion may make your foot look grotesque. If your bunion gets too severe, it may be difficult to walk. Your pain may become chronic and you may develop arthritis.
Relief from Bunions
Most bunions are treatable without surgery. Prevention is always best. To minimize your chances of developing a bunion, never force your foot into a shoe that doesn't fit. Choose shoes that conform to the shape of your feet. Go for shoes with wide insteps, broad toes and soft soles. Avoid shoes that are short, tight or sharply pointed, and those with heels higher than 2 1/4 inches. If you already have a bunion, wear shoes that are roomy enough to not put pressure on it. This should relieve most of your pain. You may want to have your shoes stretched out professionally. You may also try protective pads to cushion the painful area.
If your bunion has progressed to the point where you have difficulty walking, or experience pain despite accomodative shoes, you may need surgery. Bunion surgery realigns bone, ligaments, tendons and nerves so your big toe can be brought back to its correct position. Orthopaedic surgeons have several techniques to ease your pain. Many bunion surgeries are done on a same-day basis (no hospital stay) using an ankle-block anesthesia. A long recovery is common and may include persistent swelling and stiffness.
Adolescent Bunion
Your young teenager (especially girls aged 10-15) may develop an adolescent bunion at the base of his or her big toe. Unlike adults with bunions, a young person can normally move the affected joint. Your teenager may have pain and trouble wearing shoes. Try having your child's shoes stretched and/or getting wider shoes. Surgery to remove an adolescent bunion is not recommended unless your child is in extreme pain and the problem does not get better with changes in shoe wear. If your adolescent has bunion surgery, particularly before they are fully grown, there is a strong chance his or her problem will return.
If you have a painful swollen lump on the outside of your foot near the base of your little toe, it may be a bunionette (tailor's bunion). You may also have a hard corn and painful bursitis in the same spot. A bunionette is very much like a bunion. Wearing shoes that are too tight may cause it. Get shoes that fit comfortably with a soft upper and a roomy toe box. In cases of persistent pain or severe deformity, surgical correction is possible.

Running Shoes and Bunions____________________

The bottom line of all this is to do what you can non-surgically, really try hard, before you succumb to having an operation.  So often, the athlete with patience is able to accommodate their training to this problem without an operation. 

Those of you with bunions may have to try a number of lacing patterns with running shoes before they find the one that works best.  Here's a couple of examples.  Also, I asked my son who works for Adidas about stitching that digs into peoples feet.  Adidas shoes have techfit, a shoe upper that is stitch free and seems to me ideal for this indication.

Bike Shoes and Bunions                                               

In general, we keep bike shoes for a lot longer than running shoes.  In the latter, 400 or so miles and they become working in the garden shoes where bike shoes, as long as you change your cleats when they wear - pedals too occasionally - they can last indefinitely if they fit well. I found the following on line and even though it's 3 years old, it's well done so I'll simply copy/paste it for you.  Credit however goes to BikeRadar.

BikeFit Bunion Shoe Stretcher review



BikeFit's Bunion Shoe Stretcher is unusual but highly effective at its intended purpose

BikeRadar verdict

80.0 out of 5 stars
"For riders who suffer from point pressure and have helplessly dealt with it for years, the BikeFit Shoe Stretcher is a godsend"
Saturday, November 5, 2011 12.00pmBy 
Cycling shoes – especially ones designed for the road – are often touted for their highly supportive and stretch-resistant constructions that cradle the riders' feet in ultra-efficient cocoons. If that fit isn't just right, though, that foot-hugging cocoon can feel more like an iron maiden.
Riders with specific issues such as Tailor's bunions or bone spurs can be especially susceptible to excruciating pain. The common solution for those riders is to resort to wider or generally roomier lasts that can relieve the pressure but compromise the overall fit in the process. BikeFit's unusual Bunion Shoe Stretcher, on the other hand, allows riders to make point modifications in their otherwise well-fitting footwear.
The scissor-type device is very simple, comprising a basic ring-and-ball setup at one end and a thumbwheel at the other. To use it, just insert the ball end into the shoe, locate the ring over the spot in question, squeeze the tool, than gradually tighten the thumbwheel over time (typically overnight for us) until you achieve the desired amount of reshaping.
It's not a perfect process, especially with modern cycling materials whose mesh and synthetic leather panels are specifically designed not to stretch. The Shoe Stretcher's durable cast iron construction is more than a match for such comparatively flimsy materials but even so, our various test shoes reverted to their original shape after a few weeks. The one exception was heat-moldable shoes, where the reshaping was semi-permanent, but even with standard shoes, we found we could get longer-lasting results by moistening up and/or heating the areas in question with a hairdryer first. 
As long as the reshaping took, the difference on the road was like night and day, particularly for shoes with stiffer and more unyielding uppers. No longer did we have to leave certain sections of some shoes a bit loose to prevent irritation. We could happily snug things down as tight as we dared with no long-term discomfort to speak of and certainly no stinging pain.
Using the shoe stretcher is easy - simply insert the ball end into the shoe, locate the ring over the area to stretch, then clamp the tool down and let it set overnight: using the shoe stretcher is easy - simply insert the ball end into the shoe, locate the ring over the area to stretch, then clamp the tool down and let it set overnight

Image 3,4 Bunion Support Blog

Images 3,4 from Bunion Support Blog, 2012

Sunday, April 13, 2014

Tobacco Related Events in the US, 1900-2014

                                                                                                      Mark Twain

Hard to believe but there are those among us that train by day and smoke by night.  Like anything that's an addiction, once started, even though the desire to race quickly is strong, the grip of the addiction often wins.  Like many of you, I started smoking in HS.  By the time I was a Marine Helicopter instructor in Pensacola, FL smoking was part of my nature at 2-3 packs a day.  
However, after getting rejected by 9 medical schools the first year I applied, I made a deal with myself that if I got accepted second time around I'd pay a significant price - stop smoking.  From the instant I opened the acceptance letter to the University of Miami School of Medicine so many years ago, I haven't had a cigarette since.
Maybe we just need the right motivation.  It's human nature. 

Smoking sucks! The one thing I would say to my kid is, 'It's not just that it's bad for you. Do you want to spend the rest of your life fighting a stupid addiction to a stupid thing that doesn't even really give you a good buzz?'
                                    Katherine Heigl

Tuesday, April 8, 2014

Flying After Racing? Watch Out For Blood Clots

"I think it is just terrible and disgusting how everyone has treated Lance Armstrong, especially after what he achieved, winning seven Tour de France races while on drugs.  When I was on drugs, I couldn't even find my bike."  
                                                                       Willie Nelson

Many of us fly some distance to an event, race, smile, get a finishers medal or better, pack up and head to the airport.  This can be a dangerous strategy.  Despite being in peak condition, we may be little dehydrated (or a lot dehydrated in some cases - ring any bells here?) and this puts us at risk for developing deep vein thrombosis (DVT), or blood clots in the deeper veins in our legs.  Although these may cause us mild pain or leg warmth, occasionally there's calf swelling, but in many cases little to no symptoms. According to WebMD, When you have a deep-vein thrombosis (DVT), you need to treat it to avoid a life-threatening complication: a pulmonary embolism. A pulmonary embolism (PE) usually happens when a blood clot in the leg breaks away, travels to the lungs, and blocks a lung artery. It can damage the lung and other organs and lead to low oxygen levels in the blood. It can even be fatal!

In short, DVT can be a big deal, and like the other medical issues you had no knowledge of prior to starting this sport, like hyponatremia, understanding how to avoid DVT and it's related problems is the winning way.

First, start that re hydration in earnest before leaving the race course and continue until you are urinating again and it's light yellow.  Experienced competitors already know that depending on the conditions this make take some effort.  In an earlier blog I mentioned talking with one finisher after the race at Splasher's Restaurant located at the finish line in Kona (Thanks for the beer, Inde) who said he'd had several glasses of fluid post-race, more to drink in the condo, and two beers at Splasher's - not one, two - before we started chatting. So after what amounts to nearly 100 ounces of fluid replacement, he still had no urge to pee.

If you have some of those knee high compression hose, put them with your post-race clothing so you know to wear them on the jet home. And even though you may prefer that window seat to rest your head against the bulkhead and nap, grab an aisle seat this time so you can get up and move around frequently.  It keeps the muscles in your calves contacting and the blood flowing throughout your legs.

Note right calf appears larger than left calf from behind.

Although the development of a DVT and subsequent PE is fairly rare, I've seen it in my patients enough time to have great respect for the process.  One only needs to check Slowtwitch or other tri forum and the number of athletes who've suffered a DVT is surprising!

Those who are obese, have a blood clotting disorder, take birth control pills, are pregnant or smoke are at greater risk. If you can remember a few of the symptoms you'll be half way.  As noted above, these can be non symptomatic but then again you may notice a little calf swelling, perhaps more on one side than the other.  Or, an unexpected leg cramp. Similarly, a pulmonary embolism can be asymptomatic but frequently there's chest pain, shortness of breath, coughing up blood and a feeling of rapid heart beat or sudden sense of doom.  If this description ever fits, it's an emergency and you need get immediate medical attention.

Excellent Resource:

Saturday, April 5, 2014

How to Breathe on Both Sides/Unbridled Enthusiasm for Triathlon

"...she's bright as a button and kisses like a nymphomaniac on death row."
                                                                      Notting Hill

Although this comment was addressed to Hugh Grant about an upcoming date, are you this enthusiastic about your sport? I hope so.  Triathlon can yield significant health benefits, a sense of  well-being and perhaps even a little weight loss in motivated athletes.  USAT has over half a million registered triathletes all smiling just like you as winter turns into summer and racing is here!

Lynne Cox in action.

If you can't breathe easily on both sides, you're simply a Stone Age triathlete.  The reasons to master this skill are many.  Safety for one. If you look both right and left while you're in open water, you'll be aware of other swimmers, maybe a boat or two and have a powerful, balanced, faster stroke. How can you make your best racing turn around a buoy on your left if you only know how to breathe on the right?  I doubt you can.

Often you'll encounter a little chop or some small waves crossing your swim course.  You can keep the back of your head, and your open mouth seeking air but sucking air and water, to the wind and waves if you know how to breathe either to one side or the other.  Most successful racers do.

Lynne Cox, author of the Open Water Swimming Manual, and a swim career that includes twice setting the record for fastest crossing of the English Channel, has a few easy paragraphs that may make it a little easier for the self-coached athlete.  If it's still a challenge in your local pool, a couple sessions with the swim coach may be all you need to get over this hump and never look back.  But to look to the right and left, though.

One note of caution.  When attempting something new, it's very easy to try it for two minutes, mess it up, and say "Oh well," returning to ones previous flawed technique.  This will prove a challenge to you, one I learned 20 years ago at one of the Total Immersion Swimming weekends.*  So give it some time, maybe just a few minutes on day 1, but keep at it.  The rewards greatly exceed the awkwardness of learning something new.

Bilateral Breathing Drill from Lynne Cox

-In the pool, lie on your right side, as if you are going to swim side stroke, with your right arm extended above your head and the other arm resting on your side.
-Put your face in the water and blow bubbles.  Take a breath when needed.
-Kick six to eight times on your side.
-Take a stroke with your left arm and use the core of your body to roll all the way over to the other side of your body.  Make sure you are using your core to roll over.
-With your left arm extended, let your right arm rest on your side as you kick on your left side six to eight times with your face in the water.
-You want to maintain a straight line in the water.  Usually, swimmers are more balanced on one side than the other.  Sometimes it takes a little more concentration and work on balance to kick on one side as opposed to the other.  But this exercise will help you balance your stroke and also swim in a straighter line.  It is easy to see which swimmers in the open water have a balanced stroke.  Those who are not balanced will swim in the direction of their dominant side, off to the right or left, and not maintain a straight line.
-This drill will also help you maintain a horizontal position and enable you to move efficiently through the water.  You will be rotating from one side of your body to the other reinforcing that your arm stroke is done in conjunction with the rotation of your body, so that you are pulling with your core as well as your arms.  If you do not use your core with your arm strokes, you will not swim efficiently.  You will be swimming flat on the water, and if you are using only your arms, the muscles in your arms will fatigue more rapidly and you will tire sooner.
-This drill will also help you increase your power, speed and endurance while you are swimming.


Thursday, March 27, 2014

Accepting Thank Yous. Athletes Are No Good At It

The Grateful Patient (or Triathlon Race Fan)

Ironman race fans line the course, waiting

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

                                            Martin Tanner by Harry Chapin

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

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

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

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

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

Dear Doctor _____

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

God bless, Julie ___________

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

I’m sure.

IRONMAN Parade of Nations for the fans in Kona.

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

Thursday, March 20, 2014

Stress Fractures, Yes It Can Completely Break!

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

I got 7 races on my mind.  

Four that wanna drown me,

Two that wanna crown me, 

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

Jones Fractures 

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

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

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

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

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

Image #1, Themetapicture

Monday, March 17, 2014

Transition Obstacles -& The Miracle of Triathlon/Running

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

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

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

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

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

Transition Obstacles

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

Miracle of Triathlon/Running

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

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

Dear Doctor _____

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

God bless, Alice ___________

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


Image 1, Google Images