Sunday, February 18, 2018

Atrial Fibrillation, Afib or AF, in the Endurance Athlete



"Don't call for your surgeon, even he says it's late.  It's not your lungs this time but your heart holds your fate."          Manfred Mann



Although it might be somewhat surprising, the single most popular piece I've written here, and mind you this is a triathlon oriented blog, was on pills.  Antihypertensives to be specific; medication for blood pressure control.  So this issue will expand on that writing that addressed rapid heart rates in general and review a very commonly seen abnormal rhythm called atrial fibrillation also written AF or Afib. More people than you would guess have this issue, particularly those in the sport for decades.

Usually the heart beat is regular and labeled normal sinus rhythm, NSR.  But in Afib, the ventricles, or major pumping chambers, receive a rapid, erratic signal and pump at a varying, irregular rate.  Although some can have AF and be symptom free, others can experience chest pain, dizziness, fainting, or be intolerant to exercise,etc. They can be at a 7-8 times increased risk of suffering a stroke.

The diagnosis is made after obtaining a history, physical exam and EKG.  Occasionally an echo cardiogram or blood work are also indicated.  Then, one would search for the underlying cause to choose treatment options.  Interestingly, a common cause is dehydration.  Also found can be an over active thyroid, hypertension, certain types of lung disease, diabetes, excessive alcohol consumption, etc. although finding no definite cause is quite common.  If the diagnosis is in doubt, the patient can be fit for a monitor which continuously records the EKG for 24 hours or longer. Once this diagnosis is made, the goal of treatment is to restore the heart rate back to a normal level and diminish the risk of stroke.  Often this is more of a challenge than the patient (athlete) would like.
                                                               

Medically, a number of medications are available for stroke prevention including aspirin, warfarin and the newer (read more expensive - and to be fair, much more user friendly) agents.  When addressing the abnormal rhythm, various meds are available and, when ineffective catheter ablation may be offered.  This is catheterizing the heart, usually through one of vessels in the leg, and attempting to both locate and destroy the tracks along which the abnormal electric signal travels.  As you might imagine, it's a big deal!  I found an on line ad for the Cleveland Clinic where they advertise having performed more than 1200 ablations for AF last year with success.

I've read various posts over the years on various tri forums, readers echoing the disappointment that their medical issues not only limit their ability to train but race as well.   One athlete with significant AF summed it up this way, "I am not letting it take over my life, but it ****ing sucks that I can no longer participate at the level in endurance sports that I had been able to achieve with 20 years involvement in one sport or another (running, cycling and tris).  I even dropped out of IMLP since I knew I couldn't train for the race in my condition."  (I really feel for this guy and I know you do too.)

So, if you've recently been given the news that you have AFib and it requires treatment, research it out, get as much information as you can, and do what you and your physician think is best for you.

Support


"No One Said It Would Be A Piece Of Cake?"
This hand written note was tied to a sign at about the one mile mark of the bike in Kona in October.  A mile later there was one that read, "Cake?  We have an App for that!"  And a mile later...you get the picture.  Isn't it nice that on days when we occasionally feel isolated and exhausted, that we have friends and family to remind us that they're still there, and they care.  Make sure you thank them every day.                                 

Sunday, February 11, 2018

Xrays, MRIs, Cat Scans: When do You Need What


"How long can you stay fresh in that can?" The cowardly lion on first introduction to the tin man.

                                                                          Bert Lahr in the Wizard of Oz






A former patient of mine, upon being told that an MRI was the next step in diagnosing what was thought to be a rotator cuff tear, wanted to know how long he's have to be stuffed "into that can?"
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 A big arm of the American Academy of Orthopedic Surgeons, the AAOS, is education.  People don't always know the differences between these studies, what they show - and as importantly what they don't show - so I've reproduced this to eliminate that lack of understanding.


X-rays, CT Scans and MRIs

Diagnostic imaging techniques help narrow the causes of an injury or illness and ensure that the diagnosis is accurate. These techniques include X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI).

These imaging tools let your doctor "see" inside your body to get a "picture" of your bones, organs, muscles, tendons, nerves, and cartilage. This is a way the doctor can determine if there are any abnormalities.

X-rays

X-rays (radiographs) are the most common and widely available diagnostic imaging technique. Even if you also need more sophisticated tests, you will probably get an X-ray first.

The part of your body being pictured is positioned between the X-ray machine and photographic film. You have to hold still while the machine briefly sends electromagnetic waves (radiation) through your body, exposing the film to reflect your internal structure. The level of radiation exposure from X-rays is not harmful, but your doctor will take special precautions if you are pregnant.

Bones, tumors and other dense matter appear white or light because they absorb the radiation. Less dense soft tissues and breaks in bone let radiation pass through, making these parts look darker on the X-ray film. Sometimes, to make certain organs stand out in the picture, you are asked given barium sulfate or a dye.

You will probably be X-rayed from several angles. If you have a fracture in one limb, your doctor may want a comparison X-ray of your uninjured limb. Your X-ray session will probably be finished in about 10 minutes. The images are ready quickly.

X-rays may not show as much detail as an image produced using newer, more powerful techniques, but they're much cheaper, and if they reveal the diagnosis save the patient both money and x-ray exposure



Computed Tomography (CT, or cat scan to many)

Computed tomography (CT) is a modern imaging tool that combines X-rays with computer technology to produce a more detailed, cross-sectional image of your body. A CT scan lets your doctor see the size, shape, and position of structures that are deep inside your body, such as organs, tissues, or tumors. Tell your doctor if you are pregnant before undergoing a CT scan.

You lie as motionless as possible on a table that slides into the center of the cylinder-like CT scanner. The process is painless. An X-ray tube slowly rotates around you, taking many pictures from all directions. A computer combines the images to produce a clear, two-dimensional view on a television screen.

You may need a CT scan if you have a problem with a small, bony structure or if you have severe trauma to the brain, spinal cord, chest, abdomen, or pelvis. As with a regular X-ray, sometimes you may be given barium sulfate or a dye to make certain parts of your body show up better.

A CT scan costs more and takes more time than a regular X-ray, and it is not always available in small hospitals and rural areas.



Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) is another modern diagnostic imaging technique that produces cross-sectional images of your body. Unlike CT scans, MRI works without radiation. The MRI tool uses magnetic fields and a sophisticated computer to take high-resolution pictures of your bones and soft tissues. Tell your doctor if you have implants, metal clips, or other metal objects in your body before you undergo an MRI scan.

You lie as motionless as possible on a table that slides into the tube-shaped MRI scanner. The MRI creates a magnetic field around you and then pulses radio waves to the area of your body to be pictured. The radio waves cause your tissues to resonate.

A computer records the rate at which your body's various parts (tendons, ligaments, nerves, etc.) give off these vibrations, and translates the data into a detailed, two-dimensional picture. You will not feel any pain while undergoing an MRI, but the machine may be noisy.

An MRI may help your doctor to diagnose your torn knee ligaments and cartilage, torn rotator cuffs, herniated disks, hip and pelvic problems, and other problems. An MRI may take 30 to 90 minutes. It is not available at all hospitals.

Part of the take home here that each technique has it's strength and although many will walk into their doctor's office wondering "if I need a scan," depending on the presumed diagnosis, other tests, like plain x-rays to quantify arthritis of the hip, may in many cases be superior to some kind of a scan.

Sunday, February 4, 2018

Racing at Night, Your First Ironman. Yep, Easily Could be You.

Regardless of your abilities or expectations, you may find your first attempt at the 140.6 mile distance a really big bite, more than you'd ever planned or imagined.  It's not uncommon for the sun to cross the horizon at sunset before you cross the line an Ironman.


Ironman South Africa
Each of us has some idea of what to expect when we strap on those swim goggles, follow a whole herd of nervous newbies just like us, each with some idea of what's right around the corner of our first IM.  But most are wrong, underestimating the effort required by, in some cases, a fantastic amount.  It's like the practice of medicine in this way.  When, as a first year medical student taking Physical Diagnosis, you are learning to be an investigator, a pathfinder, what's wrong with the patient in front of me and how can I ask the best questions to help figure this out?

Part of the questioning frequently comes to alcohol, a touchy subject for many, where the student inquires as to the amount this patient consumes.  Before writing the response down and entering it in the medical record, the student is advised by the crusty mentor to think if that answer fits the situation or if it's considerably less than the truth.  While this is the exception rather than the rule, suffice it to say that there are misperceptions in both the newbie triathlete's expecations of the first IM as well as for some of us when revealing our alcohol consumption.*

So regardless of prior marathon experience, distance swims performed, local Labor Day century bikes rides in the logbook, most underestimate the effort that will be expended that day or the time to expend it.  They also fail to appreciate that the weatherman has a big influence here and the effect a warm day will have to knock the wind out of their sails.  And their legs.  One example would be local athlete Emily, a skilled competitor and Ironman finisher, who finished a recent 70.3 effort where the temperature reached the high 80's, and a half mary course where the only shade provided are the occasional telephone wires across the road.  It was hot!  "That may have been the hardest thing I've ever done!  Maybe harder than the full distance under cooler conditions," she observed.

All of the above leads us to the object of this piece that while you may not finish during daylight hours, you will finish!  Honest.  It's just going to take a different kind of effort than you may have planned while putting in laps at the fitness center.  First off, you'll have plenty of company.  There's a really good chance that you'll have to walk during the run.  Some of us nearly all of it. And there will be at least one racer if not more who will be there right with you.  With the same ultimate goal, finishing before the ultimate time cut off.  It's a pretty simple calculation to determine the required pace.  But be forewarned. Ironman is nothing if not a rule following organization. (A local VA race billed itself a "Double Ironman" until a cease and desist order was received from WTC instructing them not to.)  I have seen athletes who are mere seconds past the swim, bike and finish time cut off who are DQ'd.  Don't be surprised, they really have to draw the line somewhere, no pun intended, so do your pace calculation with room to spare just in case.

If your run course has aid stations "approximately every mile" and you can maintain just under a 15 minute per mile walking pace, you'll hit four miles per hour with a few seconds at each aid station to stock up. (Remember this though, that with decreased effort - not running - you'll have different fluid and electrolyte needs.  Less obviously, over-drinking can lead to hyponatremia, a serious medical condition that you need to be aware of for both you and you new walking friends.  As the sun sets, you will probably be given a light stick to hang from your clothing or some do well as a necklace that can be seen from front and back.  This could be important as the entirety of the course may not be closed both ways to vehicular traffic and you don't want to get squashed.

Lastly, when you finally do make it to the finish line chute, unlike the 7 hour marathon finisher, IM race fans do hang around to cheer you on those final yards. From experience, you feel a little sheepish, you've been at this a long time.  You're a little embarrassed, like maybe you should be carrying a spear and shield or something, but the second you cross that line, it all goes away.  Mission accomplished!  You're an Ironman with a big medal around your neck to prove it.  A month from now, a year from now, no one is going to ask about your pace at the nineteen mile mark, they'll just be in awe that you're an Ironman finisher.  Like Judy and John Collins, the ones who thought up this crazy thing say, "Swim 2.4 miles, bike 112 miles, run a marathon, and brag for the rest of your life."

And don't forget to shake the hands of your new found walking buddies.  They're Ironman finishers too.  But do it humbly.

Sunset on the Big Island, earlier than most people think!
*We just finished no-alcohol January 3.0 where a big group of triathletes went alcohol-free for the month.  Easy for some, quite the challenge for a few!  But huge grins on that latter group who showed that with a little help from your triathlon peers, you can accomplish most anything!

Sunday, January 28, 2018

How To Practice Your Triathlon Starts in Winter

In water race start

Think for a minute.  You're in your local triathlon.  Nervous as all get out as your wave is about to go for an in water start. (Or it could be on land, dock, etc. but we'll use in water for our example.)

Your goggles are set, you're warmed up, seeded correctly (you think) when almost out of nowhere, the air horn blasts from the race director and it's go time!  But as you saw from the above video, the athletes in this equally seeded group all have very different starts.  They haven't gone 20 seconds and already one racer is way ahead and one way behind.  Which one are you?  Is there an easy explanation for that?  Can it be fixed?

Certainly.  I guess if you take a step back and ask, "I know I'm warmed up, ready to race, but am I a one speed swimmer?  If I am, can I change it?"

Pace.  This gets back to one of the absolute key issues in this sport.  One that I guarantee every single person reading this has learned the hard way, more than once.  Hopefully just not recently.  Your goal is to have enough energy left to run the run, regardless of the race distance be it a really short sprint tri or Ironman?  Or, will you have pushed a little (or a lot) too hard on the bike due to the absolute joy of being out the water, hair still wet, flying on your steed on a beautiful summer day while the police and race volunteers stop traffic?  Yes, they're holding up traffic for YOU!  Pretty easy to see why this feeling of super powers can go to your head when you might benefit more from thinking about what your current pace will leave in your inner gas tank as you bust out of T2.  You want to run out of energy the step over the finish line, not any step on this side, right?

So back to the problem at hand. Like most things triathlon related, the solution comes from three things.  Preparation, practice in training, trial and error.  If you train for a slightly higher race pace at the gun, make several pretend race starts say the first Saturday of every month at a variety of efforts, you can figure out if you can do this slightly increased pace for 25 yards, 50 yards, etc. before slowing back to race pace looking for another pair of feet upon which to draft. (You do draft, right?)

So lets come up with two routine swim workouts that will accustom our bodies to this higher level of output initially.  Ever swim "pig in a python?"  Let's think 125 yards, 5 times.  The first round, the first 25y is fast, the remaining 100y at your pace.  The second 125y is swum 25y at pace, 25y fast, and the remaining 75y at pace.  Starting to get it?  We'll do one more.  The third round, 50y pace, 25y fast, 50y pace, etc.  The fast 25y is moving through the effort.  Pick some fairly short rest interval in between 125s like 5 or 10 seconds.

Try that as your main set one day a week for a few weeks.  Once it's old hat, we're going to make one small change.  Again we're thinking 5 X 125y.  Again, our first round is 25y fast, 100y pace.  But here's the change. Second round is now 50y fast, 75y pace.  Third round becomes 75y fast and 50y pace etc until round five when all 125y is fast.

Come summer, when the gun goes off, you'll have trained your body to push a little at the beginning of the swim and you won't get to 400 yard mark wondering why there's this truck on your back and you can't catch your breath.

Good luck and happy racing!




Sunday, January 21, 2018

The Triathlete, Arthritis and Joint Replacement 2018, Part 2, Racing?


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




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


A  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 2018.



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 to the Ironman finish line!  Well, maybe.

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

So how do you and your doctor make the decision about triathlon after surgery?  It's not an easy one and there's no right answer for everyone.  On one hand we have...the past. Two week hospitalization after surgery, traction and sometimes a delay in weight bearing, absolutely no sports noting that the literature is rife with joint replacement in the young athlete who was too frisky failing at 10 years requiring another, more difficult, operation.

Then, we have the present.  Short post operative stay, as little as over night, immediate full weight bearing, improved components and techniques, both full and half joint replacements, decades of experience on dealing with the stresses that an artificial joint sees.

Many currently feel that a strong muscular envelope around the hip or knee absorbs forces which may previously been born by the joint itself.  They also may contribute to assisting the tracking and joint function helping normalizing ones gait and joint function.  They go on to report that you'd try to run with normal/excellent form on forgiving surfaces with 2018 stress absorbing footwear.  You still understand that in some they're risking early revision surgery but others feel that to continue the sport they love at this point in their life, it's well worth the risk.




Sunday, January 14, 2018

The Triathlete, Arthritis and Joint Replacement 2018, Part 1


When the triathlete's knee or hip wears out, and the pain is more than they can bear, they find themselves faced with the possibility of joint replacement surgery.

Immediately they wonder one thing, "Will I be able to race again if I have the new joint?"

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As a foundation for this piece, I was taken back to a Training Bible Coaches review course I taught a few years ago and one of the coaches with end stage knee arthritis.  He was already on the books for replacement surgery following this course and we spent a lot of time talking about his future.  I wrote to this coach to find out things were going with the new joint and this was his response.


John- Great to hear from you.

Your memory is almost correct.

I had TKR (total knee replacement) in 2010. I saw you after that and you commented after walking behind me to dinner that I owed my life to my surgeon because my gait was so good!

And yes, I’m riding and racing. Doing rides and Aquabike up to Iron distance and racing Tri only sprint and Oly, due to recommendation (STRONGLY PUT) by my Doc, not to run longer.

It’s awesome. Bike power has never been higher.



Chuck

What Are the Risks of Hip and Knee Replacement?

Joint replacement surgery is performed for treatment of severe arthritis. During these procedures, the arthritic joint is removed and replaced with an artificial implant. TKR and THR, total hip and total knee replacement procedures are performed for treatment of severe arthritis of the joint. During these procedures, the arthritic joint is removed and replaced with a joint likely made of polyethylene and some variety of steel alloy. Prior to even considering joint replacement surgery, you should have a very thoughtful discussion with your doctor ensuring that all of your questions have been answered.  Many institutions have pre-op total joint classes intended for those who are sure, as well as the not-so-sure.  They are frequently taught by a physician or nurse who specializes in this area of orthopedics.  No question is considered stupid.  It's a real opportunity for the potential patient to determine if undergoing this procedure is right for him or her.  Also, it gives them a chance to go over the real risks and benefits of joint replacement surgery.


In the overwhelming majority of cases, replacement surgery is a safe procedure. However, there are potential complications associated with this or any surgery. All patients undergoing joint replacement need to understand the potential risks.  I read that there are 700,000 knees replaced and 500,000 hips replaced every year.




Let's look at a couple of potential problems.


Blood Clots (DVT)


Due to the nature of this type of procedure, lood clots in the larger veins of the leg and pelvis (deep venous thrombosis, or DVT) are more common after joint replacement surgery than, say, arthroscopy which I'm certain some of the readers have had. To minimize the risk of developing these blood clots, you will start you will be placed on some kind of blood thinning regimen that, in some cases, will continue for several weeks following the operation. Compression stockings are frequently worn to keep the blood in the legs circulating. Early mobilization, getting up and out of bed, physical therapy, etc. all contribute to the prevention blood clot formation.


The concern is that if a blood clot develops, it is possible that the clot can travel to the lungs (called a pulmonary embolism), which can be potentially fatal. If your doctor finds evidence of blood clot formation, you will likely be given a higher dose of blood thinning medication for a longer period of time.


Infection


Infection of a joint replacement is a serious complication.  It can even necessitate removal of the joint replacement implant. Infections sometime occur in the days and weeks following surgery (early infection) or years down the road (late infection). An attempt to surgically clear the infection and leave the implants in place is sometimes made, especially in the setting of an early infection. However, some infections require removal of the implants, followed by weeks of IV antibiotics. To reduce the risk of an infection once you have a joint replacement, you may be told to take antibiotics for dental work, colonoscopies and the like are performed.


Stiffness

When surgery is performed, you body's natural response is to make scar tissue. This is true both on the skin and deep down inside the joint. Because scars contract, a tightening of the soft-tissues around your joints can occur. If this occurs after a knee or hip replacement procedure, you may have difficulty bending your knee, sitting in a chair, or walking up and down stairs. Because of this, it is important to begin activity as soon as possible after surgery. Occasionally, physical therapy must be continued for months following the surgery. 


Failure or Loosening


Over time, implants wear out and may loosen. New technology has helped this problem, but wearing out of implants and loosening still occurs. Most hip and knee replacements last an average of about 20 years. Some last less than 10, some more than 30, but every implant eventually wears out. This is more of a problem in younger patients, who live longer and typically place more demands on the implanted joint. Obesity also contributes to early failure.

If the joint wears out, a revision replacement (replacement of a replacement) may be performed. This is a more complicated surgery, and the lifespan of the implant decreases with each revision surgery. This is one reason why physicians often delay joint replacement surgery as long as possible, especially in younger patients.

Hip Dislocation
Dislocation of a hip replacement occurs when the ball dislodges from the socket. This can occur for many reasons, but often occurs after a fall or in patients with problems such as Parkinson's disease. Hip dislocation can even occur with simple activities such as while sitting down on a low seat. For this reason, you may be instructed to follow "hip precautions". These precautions include:



  • Not crossing your legs

  • Using elevated seats

  • Not bending your hip up more than 90 degrees (toward your chest)

  • Sleeping with a pillow between your legs

  • Avoiding turning your foot inward


Is Joint Replacement Too Risky?


These are some of the common complications following surgery, though this is by no means comprehensive. Before undergoing this surgery you should have a long discussion with your doctor and ask all your questions. You may be referred to an internist to have a full medical evaluation before surgery and discuss any medical issues that may be unique for you.
Joint replacement surgery is outstanding -- the results have been excellent, and the outcome of most patients is wonderful. However, there are risks to this surgery, and it is important to understand these before you proceed.


Note: Almost 20% of patients who undergo total knee replacement find that it doesn't live up to their expectations.  this is especially true in those with mild to moderate osteoarthritis. Perhaps the expectation level was too high?  A replaced knee is not equal to "original equipment.

Next time we'll go into post op activity choices, swim - bike -run and how the athlete and his/her doc make this an individual decision.








Monday, January 8, 2018

Raynauds, Winter Riding, Fixing Cold Hands and Feet


"The Cold Never Bothered Me Anyway."



                                           




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One of the things on your off season to do list during might be get a neutral bike fit by a pro who doesn't benefit if you buy a new bike or aero bars.  This is John Cobb*, arguably one of the best fitters ever, shown here helping a masters athlete customize his bike fit.  This racer had very specific requests with regard to arm placement and potential positional back pain. This Cobb fit was most definitely worth his money.
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The Navy SEALs say "there's no such thing as bad weather, only bad gear."  

We used the same phrase talking last week about winter outdoor workouts in general. http://bit.ly/2CrA1gp

Today it's overcoming cold fingers and toes on the bike. I cover this topic each year as new readers sign on.  Here's what you need to know for 2018.


Although it’s January, and because of somewhat unusual weather patterns, we in Virginia have yet to see our first snow of the year.  Even so, it was 3 deg F at sunrise today, a good time to start this year’s discussion of cold fingers, cold toes, and Raynaud’s Syndrome in some cases.  (No, even I didn't ride today.)


 Raynaud's is pretty common. Many athletes have written to me and without knowing what they're describing, will have Raynaud's as an isolated phenomenon.  In others, it accompanies a more global process. Those affected will have more issues in cold conditions than warm, their fingers will have decreased sensation and often turn white, almost snow white.  As often as not there will also be a numb sensationin the digits as well.  Physiologically, what's going on is a spasming of the small arteries in the fingers, often when cold or even just cool. About 5% of all men, women 8%, have Raynaud's and it can affect ears, toes, and even your nose.


When rewarmed by being placed in modestly warm water for 2 or 3 minutes, or down your pants while running or riding - the closest source of warmth - the digits turn every shade of red and purple you can imagine before simply settling on only mildly red. In a few minutes, as the fingers begin to warm, they can also turn blue then a purple-red with a "pins and needles" feeling before they normalize. This whole process can take from just a few minutes to an hour and can be quickened by immersing ones hands in warm water as noted above.   Women seem to get this more than men, often in the 2nd to 4th decade of life. There are medical answers to this, and medicines to avoid, which might increase the frequency of attacks. Once warm, daily tasks like starting a car or typing become easy.


 If you want to document this, next time it occurs, start taking pictures with your cell phone, and save them for your health care provider. You will be asked about a family history of certain kinds of arthritis, bowel disease and the like. You may find that your complaints are the same (or different) but it's a good starting place.


 My sister and I both have this diagnosis to a greater or lesser degree and I think I'm the biggest local purchaser of chemical hand warmers at our local backpacking store. But, I ride outdoors all year unless there's snow or ice on the road. It was 27 degrees on a recent MTB adventure and my Raynaud's just wasn't a factor.  Outdoor swimming in Fall or Spring, however, can present a certain challenge!  Fortunately most triathletes avoid outdoor swimming unless at gun point and the thought of cold water drives them positively - well, indoors!

 That said, I've been symptomatic from this for over 30 years, my Mom longer, so it's easy to follow long term, and mostly we just live with it. As mentioned, I use chemical hand and foot warmers biking in the winter, and when it's below freezing I have some Sidi rechargeable warming inserts for my winter biking boots (they're not cheap and don’t work all that well - read don't waste your money. There may be improved rechargeable warming shoe inserts of which I am not aware.  Let me know!)  Neoprene bike shoe covers, either just the toes to block the wind, or full booties can be useful.  Ultimately, like anything in triathlon training, it's all just a matter of preparation.  So, welcome to the world of winter riding/running and possibly Raynauds Syndrome. It's an inconvenience but not much more.
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 A number of readers have had excellent ideas about how to solve the cold hands problem that can accompany winter riding. Excellent suggestions have come forth about a variety of different types of gloves/mittens/socks, chemical hand warmers, etc. Some athletes have simply chosen to ride indoors until the bloom of Spring and give those trainers a work out. If, however, you want to stay outside all winter, depending upon your climate, some alterations may be in order to remain comfortable.


 All it takes is a little trial and error. Well, maybe a lot of trial and error. I'd suggest you start by putting a thermometer outside your window to get an accurate temperature before you venture out. It's better than the Weather Channel as you may live a real distance from where they get their measurements. Then, get an idea of what gloves, layering of gloves, mittens and layering/lining of mittens you need at 50 - 55 degrees, 40 - 45 degrees, etc. If your mittens are so bulky that you may lose control of the bike, figure out something else. 


The important thing is not to layer each digit as you might do with shirts and coats, but to provide a “den” for the fingers. Mittens, more than a single layer, with touching digits and some type of warmer seem best. One thing that many over look is a product called Bar Mitts (they also have Mountain Mitts for your mountain bike) should you train on a bike with ram's horn bars. These are sleeve-like neoprene that fit right over your handle bars and block cold, rain and snow...not that you'll be riding outdoors on 25 mm tires in the snow. I hope. You don't even need very thick gloves to stay toasty. I'll admit that they may look a little dorky but the bike group conversation will quickly move on to something else and you keep your hands warm. I'll attach a couple pictures from a local riders bike.  I don't know of one for tribikes but you may.


So don't let the cold alter your training plan, it doesn't stop the SEALs for sure.
                                          

*http://www.cobbcycling.com