Sunday, August 24, 2014

Joe Friel: My Mentor, My Friend: 40 Days til Kona

This is my 500th blog post.  I'd like to dedicate it to Joe Friel, my mentor, my friend, my patient.  None of what I have achieved in triathlon would be possible without him.  From coaching me for many years and meeting me at the finish line in Kona with an ice cold beer (or two!), to being my roommate and putting up with my endless questions about human performance.  We come at this sport from different angles and often agree to disagree on various topics.  Joe has about the strongest will power of anyone I know, absolute control over what goes into his mouth or the exercise he does and it's quite contagious.  When he's designed a work out for you and the goal is not met, you feel as bad that you let him down as you do in not meeting the preset parameters.

In short, Joe Friel sets the pace the rest of us might aspire to, lives life with honor and hard work, is true to his athletes, true to his family, true his team.

So, to Joe Friel I dedicate this 500th blog.

Super coach Joe Friel (L) encouraging course record holder Bob Scott in Kona

"It's going to be a Hard Day's Night."   The Beatles

We're 40 days till the cannon blast signals the start of the Ironman World Championship. The athletes who are racing this year are beginning to struggle with the upcoming need to think about tapering, opposing that intense internal drive to get every bit of training they can out of every day. It can be as much as 20, 25, even 30 or more hours per week. Age groupers too! For the first timers on the Hawaii course there are so many questions involving bike transportation, accommodations, training on the island, heat acclimation, and learning as absolutely much as possible about the race and it's conditions to ensure they're in the annually expected 93% who finish the event instead of the handful who don't.

I think the biggest mistake that newcomers make is that in spite of spending 7, 8, 10 or more days on the Big Island, they don't get it. They are so focused on the race that although they finish well on Saturday, it's "mission accomplished," so to speak, they've totally missed the Hawaiian feeling of Ohana (family) or the spirit of Aloha. And, for those who've brought family and friends, they've learned little to nothing about this wonderful place as they become consumed with Ironman.

To be fair, it's this goal oriented behavior that got them here, but with actual pre-race training at a minimum now, there are frequent opportunities to learn and entertain while in Kona. Having been there 20 times, here are ten suggestions to ensure both the best race and the best experience for racer and family alike.  Some for you, some for the family...and some for the family to give them something to do other than watch you obsess over the race.

1.  On Sunday, a week before the race, are the light hearted PATH 5K and 10K runs.  They benefit the Peoples Advocacy For Trails Hawaii.  It's a non-profit in West Hawaii that teaches elementary kids safe cycling.  Could there be a better use of you tax deductible entry?  And it gets the family in the Big Island mood.

2. Eat at some place different every day. Splashers, Kona Inn, Fish Hopper, Jackie Rey's, Lulu's, Lava Java, they all have something good to offer.  If you really like raw fish, Da Poke Shack on Alii Drive gets rave reviews.

3.  Most peoples training plans are in full taper mode with which I agree.  But I'd suggest you start most days with a short swim on the race course.  And I'd do it at 6:50 am if I were an age group male, 7 am if I were an age group female since that's when you'll start on Saturday given the time changes for 2014 and 2015.  You can judge the position of the sun, estimate the surf, pick distant objects upon which to sight off, etc.  You don't have to swim a lot but it's fun, it's social, and where else can you swim out to a floating coffee bar Tuesday through Friday?

4. Everyone, and I mean everyone, runs the Underpants Run on Thursday, 8am, King Kamehameha's Kona Beach Hotel.  Register on line or at the Ironman Expo...and bring a camera. It's less than 2K at about a 10min/mile pace...when you can stop laughing. Bring a special hat or mask. One guy was Elvis a couple years ago and it worked. 

5. When thinking about gifts for those back home, particularly kids, both Longs Drugs and the ABC stores have a wide variety of items for not a lot of money. You will spend more money in the Ironman store than you think. ("Well, I'll never be back here again and I do need 10 more triathlon oriented shirts in the dresser.")  Consider mailing things from Kona so you won't be overweight when your luggage is weighed at the airport.  It can get expensive.

6. Say hello to some one you don't know every day. And, if they're having a little trouble since English isn't their first language, take a breath and see if you can work it out. It just takes a little patience to be a good ambassador. And besides, it's fun.

7. Get with someone who has a rent-a-car and view every inch of the race course.  You might have to omit the two mile out and back in the energy lab, NELH (Or if you're really compulsive you could take the tour and see parts of it.)  I think you want no surprises on Saturday.  And you can have lunch in Hawi.  It's really nice.

8. Be patient and kind to the people of Kona - this is their home we're invading.

9. On Saturday, say THANK YOU to every race volunteer you encounter. And every policeman.

10.  And finally, when you get to the post-race area, don't be in a hurry to leave.  Lots to see and do from finisher's medals, food of many types, pictures, etc.  Since many of you will leave Hawaii in the next 24 hours or so, and because of the stress your legs have endured and overall dehydration, understand that you are at risk for developing blood clots in your legs.  The best thing is prevention where your efforts at hydration begin now and continue until you reach your destination by air.  When on the plane, don't just sit or sleep please. Get up every couple hours, walk around, use those leg muscles - especially the calves - till you arrive home.  It'll pay off.

Tuesday, August 12, 2014

Don't Let Your Doc Do This!

It's Good to be the King!

American Tim O'Donnell
In Your Doctor's Office

 The pressures physicians feel these days have never been more intense. The gradual switch to electronic medical records, decreased reimbursements, major alterations to resident education, etc. have many docs changing the style of practice they manage. The use of physician extenders like nurse practitioners, PA's, and Athletic Trainers has never been higher. In many instances this can be a good thing. These bright, motivated medical care givers often have a great deal of knowledge and experience, plus the time to answer questions possibly omitted by the physician or surgeon. They frequently choose this line of work because they enjoy teaching, and your thirsty triathlon loving brain is just what they like.

Let me begin with two stories.  First is about a woman with shoulder pain I saw a while back.  She complained to her care giver of this problem and it was felt a shoulder MRI was in order.  Normal.  Once back in the care giver's office, there was consideration that this was potentially of neck origin so an MRI of the neck was ordered.  Normal.  In short, perhaps choosing a course where an exam by someone who knew a little more about shoulder pain, maybe even some plain x-rays, might have been a more cost saving approach. 

 That said, I know of two docs in my community who take advantage of this situation. The physician extender not only does the initial work up, orders and interprets tests like MRI's or CT-myelograms, they make the decision for surgery and do the work up, all before the patient has ever even met the surgeon. In fact, it's so bad, rumor has it that one our docs meets the patient for the first time in the OR! 4 years of med school, 5 or more years of surgical training, and the first time they ever lay eyes on the patient is in the OR!  Maybe not the best way to practice the profession.

 Short of listing some kind of patient bill of rights, in my opinion, this just really short changes the patient, YOU.  When you give your history to the doc, your story of the problem, he/she may glean something completely different from your story than the extender.  Sometimes, what may seem to you like the smallest detail, can completely change the way the data is interpreted. This then may significantly alter the tests that are ordered and your ultimate treatment.  And, in some settings, whether you've seen the physician or not, your charges reflect that you have. Remember to check.

 So, think about this next time you need medical care, ask initially what the standard is for this particular medical team or office.  Don't be afraid to state your expectations.  If things don't seem right, they probably aren't, for you as an individual anyway.  And, you can always vote with your feet.

Thursday, July 24, 2014

How to Break Your Age Group Record

Please note: my two sons and I are heading to California's Sequoia National Park for a week of backpacking and climbing Mt. Whitney.  I'll have no internet access, or electricity for that matter, for about ten days.  See you in early August.

Call me a relic call me what you will
Say I'm old fashioned, say I'm over the hill.
Today's music ain't got the same soul
I like that old time rock and roll.
                                                                                                  Bob Seger

Maybe not everything benefits from getting older

On October 11th, the age group record for the Hawaii Ironman Course in the 65-69 year old age group was 11:19:07 set in 2011.  The next day, an athlete named William Wren decided to put in a spectacular performance and dropped it to 10:44:31.  That's a 30 minute drop in one year folks!  And against the hardest competition in the world.  He managed a 1:04 swim, 5:29 bike, and 4:01 run against 35 others in his age group on race day.

What's Wren's secret?  Well one of them is, shhh don't tell anyone, he aged up!  Yep, into a new age bracket where everyone else was his age or older.  None of those 64 year old whipper snappers to race against for example.

I've written about age group record holders before and where some of them plan for a year, maybe even two years, for a day like William Wrens.  We can learn from him.  If you have a specific race or individual goal, like toeing the line on famed Alii Drive on the Big Island as part of the World Championship field, then perhaps you can pick a qualification race one year, maybe even two years, in advance to give it your best shot at qualifying.  It would be the year you turn 45, or 65 like Wren for example.  (Just to be on the safe side, you wouldn't put all your eggs in one basket, like having only a single shot at the Olympics.  There might be a conflict such as a wedding or other family issue which effectively eliminates your prime choice so you'd simply move to race "B".)

Your second step would be to drastically increase your knowledge base about the available events, comparable difficulties, etc. including checking out author Ray Britt of  He has two very easy to read books called Racing Ironman and Qualifying for Kona: The Road to Ironman Triathlon World championship.  Your goal may not be to qualify for Kona but Britt has a great deal of usable stats and advice so I own a copy of both.

Lastly, if you're going to put your all into this adventure, is there something else that you've perhaps dreamed about that will put you over the top?  Do you have a race limiter that you could devote a little more time or energy to?  Perhaps it could be professional swim lessons or a treadmill eval of your running stride that can keep you injury free while fine tuning your body for this effort.  Would having a coach help?  Well, if you turn to and their FAQ section, the answer you get is "You can take two routes: either work with a coach or do the research yourself. You’ll find plenty of books and online materials about triathlons, but we find that working with a personal coach is important for about 75 percent of IRONMAN athletes." 

I was in charge of bike inspection in Hawaii this year and I watched folks from Training Peaks ask every athlete who checked in and racked his/her bike the afternoon before the race, "Would you mind taking a one question survey?"  The athlete didn't even have to slow down to answer.  The question was, "Do you have a coach?" Over half of them said yes.

I would be remiss if I left out your support crew, your family, because if you're really going to do this it becomes a family effort like it or not.  Perhaps you offer a significant vacation - no not to Kona where you'll be as distracted as can be - but to some place of family significance where swim, bike and run are not on the agenda.  Well, they might be if you and the family were doing them together.  At their pace.

We may not all be William Wren's, whom I've been told is a really nice guy, but if we're smart enough and patient enough, we might just be able to reach that triathlon goal a year or two from now when we age up.  If Wren can, you can.

Care to be the first to rack your bike at your goal event?

Monday, July 21, 2014

Business Traveler? Here's How To Continue Your Workouts Away From Home

Author's note: I've received two notes that some of you are having trouble reading this blog on occasion.  One reader today described it as, "The white background just fades away and it's black letters over the swimmers."

If you have any difficulties whatsoever, might I ask you to shoot me a quick email  at so I can fix the problem?  Thanks very much!


Coming to a bike shop near you?

I've already been out of town twice this month teaching courses to Primary Care Physicians.  While seeing new places and meeting new people is always fun, keeping up with working out can some times be a challenge.  This can be especially true in a foreign country.  But with a little prior planning, and the Internet, you can keep a reasonable facsimile of training going.

Swimming - It couldn't be easier.  For starters, you only need one stop: . As an example, I have to go to Phoenix in November to teach a course to the American Association of Family Physicians.  I went to this site, found four groups to swim with and about 20 separate pools.  I'm drowning in choices here.  (Sorry, couldn't resist.)  So before I go I'll call ahead, ask about hours, local customs, coached work outs if I'm in the mood and I'm all set. And I always bring spare goggles.

We were in Iceland in May and simply spending time with Google, I found a place in Reykjavik that had not one but two geothermally heated 50 meter pools...and I'm a swimmer!  To quote John Sebastian at Woodstock, "I'm in heaven, man."

Running - I doubt that you need any help here.  That said, it might be nice to know where the best places to run are at your destination city that the nonexercising night clerk of your hotel may be unaware of.  A couple times I've contacted the local Road Runners Club of America folks and been given good advice.  Or stopping in a nearby running specialty shop where most of the folks who work there are runners works great.  If you were to come to Charlottesville, and stopped in at Ragged Mountain Running Shoes, not only would everyone there be able to tell you where to run, likely as not, they'd be able to give you a paper map, not only of the route but how to get there!  I doubt this experience is limited to Virginia.

Cycling - This can be a little more of a challenge. As every reader is aware, bike transport has become prohibitively expensive saved for that one "A" race per year upon which your whole season is based.  And to tell you the truth, it can be a real nuisance. I've read that some can get their bike into a hockey equipment bag and avoid the airline fees where others have folding bikes, or ones that come apart, for just such use.  They can be in several price ranges as seen here .  Spinervals videos by Coach Troy Jacobson are designed for indoor use and you might check them out also.  

Some bike shops like BikeWorks in Kona have a whole stable of quality rentals (call early because they go fast.)  Your own bike shorts and jersey are useful.  Although you can use theirs, if you bring your own pedals and shoes, and maybe even saddle and bike lock, they'll do the rest.  This may be overkill but I also bring my Road ID and under saddle emergency bag as I'm just as likely to have need of bike repair or first aid there as at home. 

For my money,Slowtwitch had a work out credited to Lance Armstrong which I copied years ago and would encourage you to do the same.  It's free, can be done on just about any hotel exercise bike, and is infinitely adjustable by you to keep it interesting.  I've done this, or something like it, countless times and always feel that my log book will be pleased when I get back home.

Lance's Traveler's Bike Work Out For Stationary Bike -  Print out and stick in your suitcase

Start with an                   8 - 10 minute Warm Up
then: Fast pedal            1 Minute
         Recovery              30 Seconds
         Fast pedal            1 Minute
         Recovery              30 Seconds
         Hard effort            2 minutes - 7 on a 1-10 scale
         Harder (9 effort)   1 minute
         Hard effort            2 minutes
         Harder                  1 minute
         Hard effort            2 minutes
         Harder                  1 minute
         Easy Spin            6 minutes
         Hard effort            2 minutes 
         Harder (9 effort)   1 minute
         Hard effort            2 minutes
         Harder                  1 minute
         Hard effort            2 minutes
         Harder                  1 minute     
         Cool down         10 minutes

It's 47 minutes and if you're type A (say it isn't so) and want an even 60 minutes, adjust as you please.

Happy Traveling!

Thursday, July 17, 2014

Seen Blood in Your Urine? Dark Urine? Read on.

Author's note: I've received two notes that some of you are having trouble reading this blog on occasion.  One reader today described it as, "The white background just fades away and it's black letters over the swimmers."

If you have any difficulties whatsoever, might I ask you to shoot me a quick email  at so I can fix the problem?  Thanks very much!

Any fellow age groupers just nip you at the line? Now's the time to prepare for those late summer and fall races to walk home with the victory.  When was the last time you practiced your transitions? Really practiced by setting up a transition area at your house or local park and going through this discipline over and over?  A surprisingly small number of triathletes do and it's such a easy place to gain time, from seconds to even minutes in some cases. 

One of the highlights in Kona, the Underpants Run. This is the silly oath.

Bloody Urine 

After a pleasant work out, and a trip to the rest room, you look down and  see blood in the toilet: now what?

 Ever looked into the commode after your long run, and instead of
the usual concentrated deep yellow urine, you
see blood?
  Or maybe just extremely dark urine?  Yep, it can be quite a shock.  But, like most things, if you take the time to do a little research you can narrow the list of
possibilities...and cancel the call to the funeral home.

 In medical jargon bloody urine is known as hematuria.  It can
range from very slightly blood tinged all the way to frankly bloody.  It's
not a diagnosis, it's a symptom.  But a symptom of what?  Let's
follow a local Virginia runner I’m familiar with, aged 25, runs 60 - 100
miles per week, is professionally coached and works in the local running shoe
store.  He obviously has a handle on correct foot wear and running related issues.  One day, out of the blue, with no particular trauma or warning, he
started with a very slight pinkish tinge to his urine after his longest runs
but over time developed frank hematuria.

 So, the first place we look is to a phenomenon called
"Runner's Bladder" as it's both the most common as well as the most
benign.  It's described as bladder wall trauma, a type of bruising, which leads to a
small amount of blood in the urine.  When the runner
decreases running volume or takes a couple of days off, it goes
away.  For a while that is, until long runs resume.  It's said that
running with a partially full bladder can eliminate this problem but it's a
level of running discomfort many can't stand.  Every heel strike reminds one of
the urine's presence.

 A visit to the urologist by our runner reveals that although
the mostly likely diagnosis is Runner's Bladder, the list of
possibilities including kidney stones, tumor, infection, various kidney
problems, etc., is pretty long.  So, to solidify the diagnosis, for
reasons specific to this individual, the urologist plans to perform a
cystoscopy - an in office procedure in which he will insert a small fiber optic
scope through this runners penis up into the bladder. ("You're going to
put a what into my where?" 
the runner was heard to exclaim!)  In
the past, predominantly because of the larger size of the scope and the pain it
would cause, this type of procedure was done in the Operating Room under

 Good news.  During cystoscopy, our athlete's
bladder wall revealed generous bruising and no other obvious source of
bleeding.  So for now, he'll continue his running career, and his
hematuria knowing that he's not causing irreversible long term damage.
Maybe he'll try again to learn to run with his bladder half full.  But at 24, with a head full of steam, he's his own man.  And,
like many other things we see happen to this athletic group from runner’s trots
to plantar faciitis, in my experience, I’ll see a lot of people with these
things once, and then never again.  Or, an  equally common scenario is that it resolves for the most part but every once in a while, again after long runs only, the urine is said to be "a little rusty."  This puts runner and family at ease, however, understanding that it's not cancer or something more serious.  As they say in Minnesota, "Good deal!

And, some months later, the problem, like so many in our athletic careers, spontaneously resolved!

Tuesday, July 8, 2014

Big Incision: When You Are Considering Going Under the Knife

Even Doctors Have Surgery

A true story of being on the other side.

The cardiac surgery team of fellows and residents was rounding on me the evening before my heart operation, and I wasn’t comfortable being “rounded on.” Six months had passed since my near-syncopal episode during an emergency department shift on the cusp of my 41st birthday; 6 months of imperfect practice as a patient. Pneumonia, rapid atrial fibrillation, and a leaky mitral valve—all a surprise to someone who thought himself too busy to be sick.

“It must be hard being on the other side,” a surgical resident said. 
I was learning that this wasn’t a question but more of a shamanistic incantation by fellow doctors eager to ward themselves against my fate. No cardiac risk factors, exercised regularly, flossed enough. Yet, here I was, wilting before puzzled faces straining to fit my illness into an unaccommodating cautionary tale.

The team left, and a tall, casually dressed woman—the chaplain—knocked on my door. She knew that I was a physician, and that I was aware of my diagnosis and the impending surgery.
“Are you scared?” she asked.
My wife sat wearily at my bedside. My son, 5 years old at the time, was back in Providence. “No,” I lied.

She smiled stiffly. “This experience will change the way you relate with patients, no?”
“I don’t believe illness must be accompanied by great meaning,” I told her. “Sometimes a crummy heart valve is a crummy heart valve.” Genuine concern tightened her face.
My wife politely interjected. “It’s been a long day.”
The chaplain slipped her card upon the bedside stand. “Patients often decide to talk after surgery.”
“Thanks. I’ll be OK.”
“I’ll ask the rabbi to visit?” I remembered the Jewish high holidays when I was younger. The spectacle, the feverish sermons, the sparkling, low-cut dresses.
“If I need an ear,” I said, struck by the chaplain’s sincerity, “you’ll be my first choice.”
I didn’t intend to be difficult, but being inside serious illness is a different experience than talking about it. The ill person’s mind earns its own logic, divines its own purpose. That didn’t include being buttoned inside a sentimental parable, or hijacked to drive a cautionary tale. I was a white coat in a hospital gown, and I simply wanted permission to be sick.

Serious illness had impacted my doctoring but not in ways the chaplain might find praiseworthy. The petty humiliations of life as a patient in the emergency department were acutely shameful—the cruel stretchers, the ugly gowns, the theater of privacy afforded by curtains pretending to be walls. As patients and families nervously awaited more information, I was inside their worry. For those unfortunate patients without health insurance, I fought harder to arrange services in a broken health care system.

But this heightened empathy and compassion were balanced by intolerance for patients seeking work notes for minor ailments and a gnawing insensitivity toward rude patients and families who lacked patience or understanding. Pity the drug seekers or patients who treated their bodies like chemistry sets.

Traveling further into illness, I discovered fewer recognizable roads for my type of journey. Months after first becoming ill—and countless failed attempts at electrical cardioversion—it became obvious that my leaky mitral valve needed repair or replacement. Suddenly, I required a cardiac surgeon. Friends and colleagues at a prestigious medical center immediately recommended Dr. A, a humanist with excellent hands. My cardiologist insisted upon a Famous Heart Surgeon (FHS) at the same institution. One of my closest friends, a cardiac surgeon at a distant medical center, counseled me about the FHS and his accolades and skills and notorious personality. He shared stories from fellows who endured the FHS’s wrath as a rite of passage.

“That shouldn’t concern you,” my buddy said. “You’ll be under anesthesia.”
My wife and I arranged to meet these two giants on the same day. That morning, we were escorted into Dr. A’s world—office of dark wood and soft chairs, silk tie precisely knotted, white coat pressed and devoid of the ink and coffee stains that marked mine. His carefully chosen words were crafted into lucid paragraphs, tailored to fit my ears and those of my nonmedical wife. His physical examination matched that of any uber-internist. I wanted him as my surgeon, friend, mentor, and life coach.

Afterward, my wife and I lunched ravenously in the hospital cafeteria. We had Dr. A in our back pocket. Our consultation with the FHS awaited us, but it didn’t matter.
He was donned in scrubs, a sport jacket, and expensive-looking leather shoes. He greeted us with perfunctory handshakes, barely acknowledging my wife. He raised my thick medical chart as if it explained everything and dropped it on his desk. “You need an operation. Questions?”

Was he kidding? He wasn’t kidding. I heard my wife whimpering for Dr. A.
I tried to penetrate the FHS’s brazen exterior, find a pulse behind the steely blue eyes that discounted my questions on complications from bypass pump and the success rate of valve repairs. I asked about his work doing mitral valve surgery with a small chest wall incision instead of the median sternotomy. The possibility of less pain and faster recovery appealed to me. He killed that option. 
“You need a Maze, too,” he said. “Atrial fib and the heart valve. You’re looking at a big incision.”
I was transported back to the intimidating surgeons at medical school and during my residency. Only I was a fellow attending now. I was a patient.

“We had a consultation with Dr. A this morning,” I said.
He nodded respectfully, then gave me a look that was scalpel sharp. “Remember this,” he said. “Your problem is nothing special. I did two of you this morning.”

We left his office feeling relieved and disoriented, as if we’d just stepped off a gravity-defying amusement ride. My wife and I slowly negotiated the corridor. We stopped, faced each other. “He’s our guy,” we declared.

The decision defied rational explanation. We had completely, and without reservation, invested our confidence in the empathic and talented Dr. A just a few hours before. But did I really need empathy, or someone to hold my hand? I reconsidered Dr. A’s responsible and cautious detailing of the surgery, his honest admission that the valve might be too damaged for repair. That meant replacement, and possibly lifelong anticoagulation. The FHS didn’t express such gravity. He seemed bored with my heart problem, even annoyed by it. Did he routinely inform patients that their problems weren’t special? Or was he savvy to the workings of the physician-patient’s mind, and his brusqueness functioned as a communication strategy?

Each time I tell this story, I’m greeted with genuine shock from students and colleagues who can’t believe I passed over the ideal embodiment of a surgeon in favor of someone who couldn’t be summed up as easily. From the moment I set eyes on the FHS, this complicated character, I knew what type of surgeon I needed—a distinguished, hard-driving, and unapologetic adversary.
How could I explain this reasoning to the big-hearted hospital chaplain?

Long after the chaplain had left and my wife went home to our son, there was a soft tap on my door. A medical student in a short white coat asked about a history and physical examination. Sleep and worry tugged on my sleeve, but I waved him in.
“Does it feel strange?” he asked when we finished, nodding to my place on the bed. “Are you scared?”
“A little,” I said. “And a lot.”
Somehow, his lack of responsibility for me and his innocent and distressed look when asking these questions upended my defenses. Fear hit me hard. I sat up higher, as straight as I could. He licked his lips. Should I tell him what I’d told the chaplain?

“Be wary of scripts that make patients feel miscast in a movie of their own illness,” I said. The student’s gaze didn’t waver. “You did a good job. Doctors can be complicated patients.”

The morning of my surgery, after a nurse’s aide nearly broke an electric razor shaving my chest hair, I lay under a sheet in preop, more naked than I’d ever thought possible. The FHS entered. We shook hands for the first time since our meeting several months before. He appeared well-rested, freshly showered. He kept tapping my chart as if he couldn’t wait to start. How can I describe my emotions? My fear was swept up inside his energy, his confidence, his focus. So much was happening that resisted making any sense. A sedative started swimming through the IV. I didn’t feel calm. My body asserted itself, assumed a weightless density and cocky buzz, and I welcomed its invitation to retreat into it.
“See you inside,” the FHS said. 
Those words played with me. Did he mean inside the operating room, or inside my chest? He was about to turn away, but stopped. “What are we doing again?”
Was he serious?
“Mitral valve? Maze?”
“That’s right.” He delicately drew a straight line with his index finger over my chest. “Big incision,” he said, and winked.

Jay Baruch, MD
Alpert Medical School at Brown University; Providence, RI 02903

If you enjoyed reading this piece, this author has also written Fourteen Stories: Doctors, Patients, and Other Strangers (Kent State University Press, 2007)

Monday, June 30, 2014

Pain in the Knee, What if it's Arthritis? Microfracture

Safety Note - I saw a gent riding his bike down the street recently, no hands, texting on his cell phone, paying absolutely no attention to what he was doing or the cars coming up from behind.  You talk about a recipe for disaster!  I'm hoping this is never you.

Must be good to be number 1

"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

I've addressed knee pain before but since it's such a common problem that takes people to their medical care giver, let's go over where we are in 2014.  Like the e-mail from this athlete we'll call Tina.

Dr. Post, 
I recently had an MRI that indicated "full thickness chondral loss along the apex and medial facet measuring 0.8cm in dimension -focal severe patellar chondrosis. The initial injury occurred in a hockey game, and I made it substantially worse over a year attempting to cycle and elliptical. Currently simply walking 500 feet causes discomfort. 

My OS gave me orthovisc injections, and sent me to physio to try to strengthen my VMO. There has been no improvement whatsoever. 

I'd like to attempt some type of surgical fix. Would microfracture be a reasonable first step?

                                                                                                                      Tina Triathlete

This is a request from an active athlete who wishes to remain so.  Tina is describing a  problem with the articular or joint lining cartilage. The phrase "full thickness chondral loss" refers to the cartilage on the back of her knee cap.  Although we as humans seem to tolerate arthritis in this part of the joint better than the weight bearing areas, Tina has an area where the cartilage has been worn completely through down to the underlying bone.  Although this sounds like something old people - watch it there, Post - have, it's really quite common in the athlete.

When the joint lining cartilage begins to break down, arthritis if you will, the owner has a problem.  It doesn't happen overnight and very frequently the owner of the knee is hard pressed to remember a specific accident or incident that lead to the current complaints.  Initially of course, conservative (read non-operative) options are tried including activity modification, NSAIDs, injections of various substances, maybe even physical therapy or bracing depending on the situation.  If these prove unsuccessful, the talk may turn to arthroscopy of the knee, usually performed in the outpatient setting under either general or regional (not local) anesthesia.  Two or three, one quarter inch incisions, so small that suture closure is rarely necessary, is all it takes.

One of the tools available during arthroscopy is known as microfracture. The goal is to get the body to use it's own resources to "heal" this cartilage problem. Although not a cure for arthritis, it can produce a new type of cartilage where there was little to none, in selected patients, and upwards of 80% of patients exhibit a reduction in pain and swelling and improvement in function.

During microfracture surgery, if the surgeon feels the patient qualifies, a small awl is placed through the arthroscopic holes and a series of small "holes" or punctures are made in the arthritic area about 4mm apart to allow bleeding and the formation of a uniform clot. Slowly, over time the clot matures and patches the damage. Crutches are often used for the first 6 weeks or so but motion is encouraged. Rehab might include Physical Therapy, weights, stretch cords and occasionally a brace. My patients would not be permitted to return to sports for 4-6 months following the procedure, some even longer if they participated in a jumping sport. This would best be determined by one's Orthopedist who knew the exact size and location of the lesion. Most patients continue to slowly improve over the first year post-op, some even the first two years.

A small percentage will fail and they may become "ex-runners" knowing that some day they may need further knee surgery of a greater magnitude. Although there are a host of knee arthritis procedures, this one has given many mid term happiness and a return to athletics.

Surgeons have tried a number of different options over the years to try and make this a life long repair. OATS, Osteochondral Allograft Transfer is one attempt.  It allows the operating surgeon to transplant normal articular cartilage from one part of the knee to another.  But, the indications are pretty narrow.

In this months Journal of Arthroscopy and Related Research a study by Steadman, et. al. discusses the use of stem cells (See my blog from 10/25/2011) to augment microfracture.  They note that "Arthroscopic and gross evaluation confirmed a significant increase in repair tissue firmness and a trend for better overall repair tissue quality..."  Although this particular study was done in horses, I suspect that further studies using a human model are right around the corner. Physicians have been harvesting stem cells (frequently from an area of the low back) and re injecting them for a variety of conditions over the years.  One such treatment is called Regenexx ( see www.regenexx.comm) where, for a host of conditions, the non-surgical use of stem cells seems promising in the short term.

A fascinating recent development in cartilage repair is called BioCartilage, "designed to provide a reproducible, simple and inexpensive method to augment traditional microfracture procedures.  It is developed from allograft cartilage that has been dehydrated and micronized. BioCartilage contains the extracellular matrix that is native to articular cartilage" made by the Arthrex Corporation.

                                                                                                                                                                          Biocartilage 0 large

This is a relatively new product but the hope is that it produces a more permanent match to one's own articular cartilage.  If it develops a successful track record over the long haul, it could be a real boon to the athletic community.

"Hold on to 16 as long as you can, changes come around real soon make us women and men*."

Tiny little creatures that live in your closet and sew your clothes a little bit tighter every night.

Images 2, 3 Arthrex Corp
* John Mellencamp