Saturday, March 28, 2009

Speed Work Is For You

For many athletes, the Spring brings not only the forsythia but a clear view of the racing season ahead. Transitioning from base training (high volume/low intensity,) workout durations seem to decrease while intensity picks up. The triathletes thoughts turn toward speed work. Not only is this true for sprint triathlon racing but iron distance as well.

WARM UP Since I'm an injury prevention guy, I feel that the warm-up may be the most important part regardless what type of speed work you contemplate from intervals on the track to fartlek to good old fashioned indian file. 15 or 20 minutes of conversational pace running, likely not done on the track, allows you to plan your stretching and the workout. Your goal is to educate your legs to run faster by doing so in shorter distances keeping that injury demon at bay. Many will conclude their warm up with several pick-ups over 50-75 meters at a quick, choppy pace.

DISTANCE Since your interval pace will be quicker than race pace, your interval distance might be 800 meters or a mile for 10K's and half marathons but 200/400 meters for shorter races. Everybody wants to run the first interval the fastest when, in fact, it should be the slowest! Like warm up part 2, or, instead of a descending pace workout each one will get harder and slower and you get more and more frustrated. So, keep an eye on your watch as you pass through 100, 200 and 400 meters to stay on your target pace. Again, run too fast and you spoil the workout and risk injury. This is a controlled effort. At the 800 meter/1 mile level you might start with 4 repeats, 8 reps at the shorter distance.

RECOVERY Many pay little attention to this important phase of the effort. The faster you run the more you rest. A general rule is to walk/jog at least half the length of the interval, maybe even the full length but not so long as to cool off.

COOL DOWN Again,this is critical. Proceed away from the track to run/jog at a relaxed pace for 10-15 minutes. The variety that this effort brings can provide tremendous satisfaction, a real sense of the job well done to the athlete! As they used to say on the Alka-Seltzer commercials, "Try it, you'll like it."

Saturday, March 21, 2009

Athletes With High Blood Pressure, Beta Blockers

I've seen questions about high blood pressure recently, or hypertension as your doctor would call it. Many of us, including this author, take daily medication for this condition and wisely so. I recently fielded a question from a reader about his anti-hypertensive medication, Inderal, and it's effect on his heart rate. I thought the response would do well here.

Ed-I'm John Post, MD, the medical director of Training Bible and Joe's forwarded your e-mail to me. I think your answer is more complex than you'd anticipate. You don't mention why your physician has prescribed a beta blocker for you. As you're likely aware, this class of drugs can be useful for a host of issues including hypertension, migraine prophylaxis, glaucoma, heart rhythm disturbance to name a few. One indication I find quite interesting is using it for "nerves" or "stage fright,"...the yips, as they are frequently taken by musicians when performing on stage to combat performance anxiety. The World Anti Doping folks take a dim view when they are illegally used by archers or shooters as NBC showed us in the 2008 Beijing Summer Games when they DQ'd one of the shooting medalists.

You note a reduction in heart rate, the primary mechanism of action of beta blockers. This would pertain to resting, submax and maximal HR. For the non-athletic world this is a good thing and in many cases will actually increase longevity given selective symptoms. That said, some patients are more susceptible to the side effects and complain of lethargy, a decreased ability to exercise and the feeling that it's hard to push themselves to the max. You don't mention much along these lines.

So, with respect to HR Training , HR zones, AeT and your goal to push a bike 25 mph, the use of tables or methods intended for those not on these agents will not work for you. I talked to my friend Jay Dicharry who runs the University of Virginia Speed lab, and has had thousands of athletes in the lab for LT testing, AT determination and the like, and he suggested that the most accurate way to figure this out was on the bike in the lab and serial blood tests-at the same time of day (and on the same dose of medicine) as your normally train. And, it's not all that expensive. From these data points, you and the trained professional could simply crunch the numbers and come up with the best estimate for you. There's probably one of these in your area but if you find yourself in Virginia and wish to schedule one these, Jay can be reached at 434-243-5605. In fact, he did my treadmill testing.

Lastly, assuming you take this for only hypertension, there are other classes of agents that work by different mechanisms of action that your family physician has in his/her armamentarium that might also be appropriate for you that don't work through HR modification. Why not have that discussion nxt time you're in the office? Good luck and safe training.

John

Saturday, March 14, 2009

Posterior Tibial Tendon Problems


We have to take good care of our feet to do what we do. Many have learned the hard way about Plantar Faciitis, metatarsal stress fractures, interdigital neuromas and the like through unplanned interaction with the medical community. I have always felt the more knowledgeable the athlete the better. The ones with problems who end up in my office who've already asked around or researched their concerns on the net seem to be in a better place to help me help them.

Athletes frequently complain of two types Posterior Tibial Tendon difficulties. The first is a slow, subtle deterioration process that actually tears or can even stretch the tendon leading to what's known as an acquired flat foot deformity. The tendon has slowly, over time, lengthened and can, in some cases, no longer do it's job in maintaining the longitudinal arch of the foot. In other instances, the tendon will actually rupture frequently leading to surgical repair. Those who seem to be at higher risk for this injury are the obese, diabetic, rheumatoid arthritics and those who may have had a steroid injection in the area.

I used this B&W out of one of my old Anatomy texts as it shows only the business part of the PTT (labeled Tibialis Posterior)coursing behind the tibia and inserting on the navicular.

So, if you have pain over the inside of the ankle, get it checked out. Your doctor will examine the ankle looking for tenderness over the course of the tendon, swelling, weakness...and those with a real problem...a gap in the tendon. The doctor will check your muscle strength by asking you to stand on your toes or determine if there's an asymmetry in he longitudinal arch while weight bearing. Although this is usually a clinical diagnosis, an MRI may be required. In my office, although tendons are not normally seen on x-ray, a plain x-ray always precedes an MRI.

If a PTT problem is noted in the early stages, a supportive orthotic might be recommended or even a cast. I'm partial to casts. If, over time, the problem continues to worsen, then an operative procedure may be recommended to repair the tendon, occasionally using a nearby tendon as a graft. In the worst case scenario a fusion of the foot bones is done to restore the arch of the foot. As you might expect, rehab is considerable and even with appropriate treatment, one's triathlon future might be in jeopardy.

Saturday, March 7, 2009

Microfracture in the Triathlete

I was recently asked by an athlete to discuss microfracture of the knee as she'd just had this done and it's been a topic in the Slowtwitch forum. Easy.
When the joint lining cartilage begins to break down, arthritis if you will, one of the tools available to the Orthopedic Surgeon 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 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 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.

Monday, March 2, 2009

Patellar Dislocations


Patellar dislocations seem to be "going around" like the flu. Hopefully it doesn't "infect" you. This injury needs to differentiated from the much more common patellar subluxation. Think of the dislocation as complete separation of the knee cap out of it's groove, subluxation only partial.

Reviewing the bony anatomy of the knee, we remember the femur above, tibia and fibula below, and the patella right out front. The tendon above is the quadriceps tendon and below the patellar tendon. Normally, the patella tracks up and down over the front of the femur and is held there by the significant forces involved in flexion and extension. These forces across the patella can approach 8 times body weight. Thus, as one's weight approaches 250 lbs there can be literally a TON of pressure that the patella sees. In those patients who are ligamentously lax or who've demonstrated instability the patella does not stay centered in the femur. This can be an extemely common form of anterior knee pain, particularly in the young. Those of us who are a little knock kneed or have a wider pelvis can find themselves in the at risk group.

Patellar dislocation on the other hand is usually post traumatic and in almost all instances the patella slides/is knocked out to the outside. Bike accidents, wrestling, snowboarding, etc., can all lead to this injury. In most cases, simply straightening the knee will relocate the dislocated bone although when this occurs, damage to both the patella and femur can result. It can even lead to loose pieces in the joint. Significant swelling can be expected.

Evaluation includes a thorough examination (both knees), x-rays, and in certain circumstances an MRI. An arthroscopic examination may be required to address the above and to evaluate patella tracking, which if abnormal may be addressed surgically. Not everyone who dislocates gets scoped.