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.

Amenorrhea
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
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 

rest."

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 atwww.acsm.org
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 

Tuesday, May 17, 2016

Women in Triathlon, Physiological Differences, Anemia, Part Two of Four


"Between two evils, I always choose the one I haven't tried before. 
                                                Mae West
___________________________________________

This is part two of four of a series intended for the female triathlete.  Previously, we learned of a woman from Virginia, marathoner, Ironman finisher, etc. as she describes her pregnancy and how it impacted her sporting desires.  Today will be injury patterns, differences female vs male athletes, anemia in the female athlete, etc. Why the treating sports physician needs to think differently treating athletes of each sex.



This is a Sports Med lecture from my friend Bill Vollmar, MD Lancaster, PA.

No longer should we be discussing the advances women have made in athletic activity and competition.  We now must push the knowledge base for female athletes to the same level as male athletes.  The recent decade has given us much information on treating the female athlete using evidence based medicine but much still needs to be learned.
____________________________________________________

Athletes:  Male vs. Female
The significant differences between male and female athletes begin just after 10-12 years of age.  The advent of puberty starts these changes.
  • Females reach peak physiological and skeletal maturity before males.
  • Females develop more body fat and less lean body mass than males.
  • Females have less upper body strength even with training but lower extremity strength is much closer in parity with males.
  • Although males have greater red blood cell counts and hemoglobin levels, work capacity studies show minimal differences in oxygen uptake when body size and composition are equally compared between males and females.
  • Women have a wider pelvis and lower extremity alignment different from men that may predispose to injury.
  • Women have shorter limbs relative to body length than men.
  • Women have increased ligamentous laxity compared to men.
Both males and females go through the same physiologic changes with athletic training and can gain significant increases in strength, power and muscular endurance.  This is true even for the aging female athlete where studies show that exercise training can still increase the size and strength of conditioned muscle.
 Women are at greater risk than men for anemia.  Decreased iron stores are found in 40-50% of adolescent female athletes without the presence of overt anemia.  

Runners are at greater risk during their training season.  Black female runners have twice the incidence of iron deficiency anemia of white adolescent female runners.  In making the diagnosis of iron deficient anemia, be sure to differentiate this state from sports anemia which results from expanded plasma volume with a normal red blood cell count.  Although only female athletes at high risk for anemia or those with history of anemia should be screened,  some feel that all female athletes should be taking iron supplementation.

Injury Patterns in Female Athletes
The NCAA has been collecting injury data since 1982 for both male and female athletes.  It is hard to compare even on a sport to sport basis as there are different rules and different activities even within some sports like gymnastics and lacrosse.  In soccer and basketball were activities, rules and equipment are similar, females injury rates are 2.6 times greater in soccer and 3.6 times greater in basketball.  In fact soccer followed by spring soccer show the highest rates for female athletes where for males football and lacrosse show the highest injury rates.  Consider the following facts.
  • The ankle is the most commonly injured body part in both males and females.
  • Females sustain 4.9 times the ACL injuries; 2.5 times the collateral ligament injuries; and 1.9 times the meniscal injuries compared to males.
  • The majority of ACL injuries in females are of a non-contact mechanism.
 The higher knee injury rate for females is well established and probably has a multi-factorial reason.  The simple diagnosis of anterior knee pain is much more common in females and most easily explained by the physical changes that occur to the pelvis and lower extremities during adolescence.  This may also be part of the reason for the increased rate of ACL tears in females.  Femoral anteversion, external Tibial torsion and foot pronation of the foot combine to create much greater stress on the ACL than in male athletes where the straighter leg can rely on the more dominant hamstrings for support.  The hormonal influences and laxity combined with the above mentioned alignment issues lend to greater injury to the ligaments which in turn increases the risk to meniscal and articular cartilage.

 Studies have shown that plyometric jump training programs for female athletes can increase hamstring strength and approximate male hamstring-to-quadriceps isokinetic testing.  This improves jumping heights and is suggestive of protecting the ACL but final outcomes are still unknown.

 There are also studies showing estrogen receptors within ligamentous structures.  Estrogen inhibits type I procollagen synthesis and proliferation of fibroblasts in vitro but in vivo functions are still unknown.

 Upper extremity injuries also are influenced by the differences between males and females.  Shoulder laxity in swimmers, gymnasts and cheerleaders forms as a vicious cycle of overhead activity combined with physiologic instability leading to impingement and rotator cuff weakness.  Laxity issues also contribute to elbow and wrist injuries particularly in sports with aerial maneuvers where the upper extremity may become a weight bearing limb. Attention to the strength and conditioning aspect of triathlon is well rewarded in this group by diminished time away from sport.

Smiles abound at the Underpants run in Kona

Monday, May 16, 2016

Pregnancy, Competitive Female Athletes, Part One of Four


This is part one of a 4 part series on the female athlete. Today we'll peek in on the pregnancy of a local swimmer and how she melded both pregnancy and pool.  Comments from other athletes follow to give the reader a multi-sourced sense.
__________________________________________

As a man, despite both having both been to medical school and being married, my knowledge base here goes only so far.  (I can hear the "Amen's" from here!)  Like me, our featured athlete Andrea is a member of the Virginia Masters Swim Team. She's been a life long athlete starting with soccer as a kid, then catching the marathon bug, triathlons and even an Ironman as an adult and currently participates in a local multi sport series.  She joined Masters swimming to improve her technique and allow her to be competitive during non-triathlon months. Although this may seem a little lengthy, I'd like to give you her (nearly) exact words as it really imparts her emotional input.

____________________________




     "When I initially found out that I was pregnant, it was right at the start of the triathlon season.  I had also just splurged on a new time trial bike.  It was difficult for me but I decided that I would defer all of my triathlon race entries and opt out of swim meets and road races while I was pregnant.  However, I fully intended to keep up all training for the duration, which I luckily had been able to do.

     I would like to share what worked for me and what didn't, not specific to swimming Masters.  During the first trimester, I basically continued exactly what I'd been doing and alerted my coach to my new condition. I wanted to move out of the "animal lane" with swimmers I find difficult to challenge non-pregnant but subsequently found myself in another "animal lane."  We are all distance swimmers and love open water, so overall an internally intense lane, yet supportive of one another.  I also noted that morning practices really helped to alleviate both morning sickness and those carbohydrate cravings. 

      As I entered the second trimester, the morning sickness went away and I had more energy.  I continued with my advanced workouts and kept my yardage at around four thousand.  However, my intervals definitely got slower. I used some of my older, stretched out suits and several team mates donated suits on their way to swim suit heaven.  I didn't find a maternity competition suit anywhere.

     Then the most difficult trimester came.  I slowed considerably with all intervals and distances.  I still did fly, my favorite stroke, but very, very slowly.  My flip turns took on a whole new format as I had to hold both arms out to balance myself as I flipped.  Breast stroke was nice, too, as it took the strain off of my lower back.  Fins and pregnancy do not agree.  Pregnancy and pull buoys don't really mix.  It seemed impossible to do a flip turn with a giant belly and a pull buoy.  Also, I drank at least two bottles of water during our 90 minute practices which seemed vital.

     Toward the end of my last trimester, my team mates joked that I might have the baby in the pool.  One of our lifeguards seemed quite alarmed when I asked him if he'd had any training in delivering a baby.  One of my team mates is a doctor, but he mentioned several times that he was not that kind of doctor!

     So, now the final surprise.  The baby was breech, but, possibly from so much swimming,he flipped into the correct position. Five weeks before my due date, after dinner and a party, I awoke at one a.m. with my water breaking.  It was New Years Day, barely.  Luckily we found a sober doctor and, a quick C-section later, Henry Anthony Latell was born 1/1/2012, the first baby of the New Year.  After a few initial days in the NICU, he was pronounced healthy and we all went home. The (helpful?) swim team offered theories as to why he came early including a distaste for being "in the front seat" on flip turns. Some said he just wanted to come out and do his own flip turns.

     I have had an amazing experience swimming pregnant with my team. Many have come to our house to deliver a home made dinner and to see Henry. Also, the team splurged and gave me a gift certificate for a much needed massage.  We have a close, special and supportive team.

     Swimming definitely kept me in reasonable shape and made me feel so much better mentally and physically. I gained the recommended amount of weight and bounced back pretty quickly getting back into the pool 9 days after Henry was born.  I have been bringing him with me and putting putting him in a nice corner spot while I take an end lane near him.  I have been able to swim for about an hour in between feedings and he seems totally content with familiar pool noises around him. I'm back to
my pre-pregnancy intervals and pre-pregnancy weight. I also think that this activity has done wonders for post-partum blues.  My OB was well aware of my fitness regimen, both supportive and knowledgeable regarding what I should and shouldn't do while training pregnant.

     The general consensus is that Henry will be a swimmer.  But since he's so quick out of the blocks, a sprinter for sure."

Andrea Latell

P.S.  When I asked Andrea  later about her attention to other sports while pregnant, this was her reply:

 " I ran and cycled the entire time. I ran much, much slower at the end and incorporated a little bit of walking. Biking on my trainer was no problem at all, however I couldn't get into my aerobars so just biked upright which worked okay. I did the exact same with my first pregnancy.  I also did some modified pilates, yoga and weight training. I gained 26 pounds and lost all of it within two weeks. I'm also nursing and plan to for a year. I did with my older son and still did all of my racing and even ran one marathon when he was about six months old. I think it's just important to eat a lot when you are training and nursing and to eat healthy and drink a ton of water.


Images, Andrea Latell
____________

Wednesday, May 11, 2016

You Say You Can't Run Right Now? Always Injured?



"Man's most valuable sense is a judicious sense of what not to believe."    Euripides 

There are more tri forums out there than you can shake a stick at.  Many opportunities for the give and take of advice, especially when the questioner has some type of physical issue that, more than likely, has been experienced by others in the forum.  But, when questions are answered by an anonymous poster, how valuable is the response rendered?  Does Captain Underpants really know whether or not I should get a PRP (Platelet Rich Plasma) injection into my Tennis Elbow or is this bogus advice?  In other words, before you'd follow the suggestion of what tires to purchase or anything related to triathlon really, know the source of the recommendation and if it's valid.

A short while back, Jeff Yeager, a level headed participant in the Slowtwitch.com tri forum, posted the information below as one way to allow the body to adapt to the changing stress levels placed on it by triathlon.  I have posted the statistics before that in recreational runners, upwards of 50% will have a running related injury this year and it climbs closer to 65-90% for marathon runners and triathletes.  Here's Jeff's approach (printed with permission) which has worked for many athletes.  You might be one of them.  At first glance, his preaching may seem too slow-paced for many.  When understanding that one's goal can first be injury avoidance, and only second - a distant second actually - performance improvement, we can begin to see the sagacity in these writings.

Hawaii 2009 057

From Jeff Yeager:

This is a public service announcement.

I always hear non-runners, some sedentary, some cyclists or swimmers, saying that they can't run because "insert statement here about a bad piece of anatomy".

I think that in 95% of these cases these people have not attempted to adopt a running program in the proper way.

Before I go any further I want to go on record as saying that for people with a serious existing injury or degenerative disease that persistence won't pay off in your case. If you have a specific diagnosis or medical advice, don't follow my suggestions.

We have all heard that contrary to intuition, triathletes experience running injuries as often or more often than runners (here 'runners' means someone that focuses only on the sport of running).

The reason for this is simple. By running every day, runners adapt to the stresses of running far more readily than a triathlete does. Running is all about physical adaptations to the specific stresses of running.

Change your mindset about running and stop considering your running 'limiter' to be your cardiovascular or muscular endurance. First and foremost it's the ability of your bones and connective tissue to endure the impact.  What worked for you when you were 16 years old and joining the track team doesn't work for you later in life when you are probably heavier and have far less growth hormone coursing through your body. And besides this, many high school and college running programs have a 25-50% injury rate each season!

When I returned to triathlon (and running) about 5 years ago I began to experience a string of running injuries one after another. They all occurred before I even exceeded 15 miles per week and affected me nearly continuously for 4 years.  There were shin splints (repeatedly), plantar fasciitis, aching knees, a serious run of SI joint dysfunction (2 years!), torn calf muscle, finally culminating in a torn plantar's fascia that resulted in a whole season of racing but no run training.

When I began to return to run training once again here's the approach I took:

5 minutes of running on a treadmill 3 days per week. I did this for 3+ months. I then moved to the next phase which was 10 minutes at a time. Phase 3 was adding 5 minutes on the other 2 weekdays between the 10 minute days.  Right now I am 1 year in to my VERY gradual build and I'm doing alternating 2/5 mile runs on weekdays with a Sunday run also. I'm still building and will be for 1-2 more years.

The big breakthrough is that now after a 5 mile run in the morning I feel like I could go for a second run in the afternoon. The next morning when I get out of bed I don't feel any of that leg tenderness that I've been plagued with the next morning for 5 years.

I attribute this to 2 things:

1) allowing my build to be VERY gradual knowing it was all about conditioning the body to the trauma, not for the cardio benefits.

2) running 6 days per week.

In regard to your running you need to change your mindset. You aren't training to be a killer runner next season, but 3-4 seasons from now. Your best friend is being injury free so you can run every day. Even 3 miles per day every day for 3 years will have you racing faster than going from 50 mile weeks with speed work to 3 months injured over and over again.

The body adapts when it receives a stressor that exceeds it's current adaptation level. This is why those extremely long weekend rides are important for Ironman. It's why those long weekend runs are so valuable for marathon.  If you were immune to injury then running 3 days per week with a 20 miler on the weekend would be a great way to train for triathlon, but it's a recipe for injury unless you are starting out as an avid single-sport marathoner already.

So my advice for you is simply this:

1) if you are 'fragile' then take a far longer view of your run training and start with something that seems pointless: 5 minute runs. (or whatever amount you KNOW is easy on your body)

2) Run 6 days per week. Fit this in to your current routine by adding 5 minutes of running either after your bike or after your swim on the days you don't normally run. This extra 5 minutes on off days should be easy because it's only 5 minutes. And doing it after the swim or bike? That's because you are already warmed up and I think that our bodies are a bit like car engines. In a car engine 90% of the wear the engine experiences is during the first few seconds after a cold start. I think that much of the trauma our bodies experience when running is the first mile and that is largely mitigated by never starting a run cold.

3) When it's time to add intensity (perhaps a YEAR in to a daily running regimen?--Remember this is talking to those prone to injury), then I suggest adding the intense running in the same way you added slow running...some ridiculously small amount initially....like 5 100 yard stride outs...then eventually becoming 5 minutes of speed/tempo placed in to a regular training run and over the course of many months you will ONLY THEN be ready to do a 'typical' speed workout seen in many training plans.  
_________________________________
Put this in the back of your mind as one way to approach this thing we call training.  WWED?  Or,What Would Euripidies Do?