Wednesday, August 29, 2012

Saddle Sores - ever had 'em?, Plus, Kona Tips 2012








"Truth hurts.  Maybe not as much as jumping on a bicycle with a seat missing, But it hurts."  Leslie Nielsen, Naked Gun 2 1/2






If you've never had this ailment you are most fortunate.  It can really be a "pain in the butt."


____________________________________________________________________

Most of the news about Lance this week is negative but, at least one source is positive.  Here's some balance for your life.  It's good!  It's Rick Reilly.  http://espn.go.com/espn/story/_/id/8310275/armstrong-worth-honoring
___________________________________________________________________ 

Those of us, and there are many, who ride a good deal, not infrequently find ourselves with irritation of the buttock which, if we're not careful, can progress to full fledged saddle sores.  And if that doesn't slow you down....

Obtaining the best saddle-rider fit can be a process which takes months if not years for optimum results.  With different materials, contours, sizes, levels of firmness, etc. it wouldn't be unusual for a rider to go through five or more saddles before the best fit is obtained.  And even then, you may not be absolutely pain free. Bicycle shorts or bibs with any one of a number of chamois (butt pad) shapes and densities, chamois creams, etc. can be variables to assist in solving comfort issues.  For an excellent discussion of this, see Jim Lampley http://www.jimlangley.net/crank/bicycleseats.html .  He is open to contact and enjoys helping solve your seating requirements.

First off, Buttock deterioration is graded in three stages from simple abrasion of the skin all the way to the open, and sometimes infected, sores that can require surgical drainage when severe.  So here are a couple rules to live by to keep this problem at bay.

1.  Friction is your enemy.  Anything you can do to keep it to a minimum will benefit you.  Examine your bike shorts ensuring that there's no seam or pressure point where there are bumps or ridges.  Consider experimenting with various types of chamois cream.  I've tried many chamois creams over the years (most recently DZ Nuts, supposedly from Dave Zabriske) and always come back to Assos even though it, and everything else they sell, is so expensive.  Plus it's very water soluble and easy to wash out your cycling gear.

                                           Assos Chamois Creme -- Saddle Sore Preventer

2.  Cleanliness is next to godliness.  If you had this problem, then it's clean shorts with chamois cream every ride, removing the shorts immediately and showering.  If the skin begins to break down a  bit, a lot of folks use pimple cream, anything with 10% benzoyl peroxide available OTC (as per the directions on the box) short term.  Occasionally one of the antibiotic gels like erythromycin (Emgel) is needed.

3.  Change bike seats for a while, different brand, just to change the pressure your rear end sees. While riding, if you can move around on the saddle, stand, coast downhill putting his weight on the pedals, shifting around can be helpful.  

4.  Is your saddle height correct?  This is key.  They say if it's too high, even a little, that side-to-rocking can contribute to imbalance and.......... and it's easy to fix.

________________________________________________________

Kona Tips 2012

Volunteer for the race as it could be the highlight of your vacation.

It takes about 5,000 people to put on this race and you could be one of them.  There are openings helping inspect bikes, assisting athletes rack their gear and bikes, giving out food and water at the aid stations, just about anything you could imagine.  You need to be 16 to register on line but many of the run aid stations in particular encourage family participation.  All of my kids have done it as have many of the participants of the Primary Care Sports Med Course I used to chair in Kona. Check it out at http://ironmanworldchampionship.com/volunteer/  .  Do it today.

If you're racing, a hiking/trail running style head light is a good addition to your preswim bag, along with that second set of "what if the strap breaks on my goggles when I put them on race morning" goggles.  It's still very dark in the transition area early in the am and although volunteers will have flashlights, the prepared racer can handle anything.

                                   
Image 1, Lovingthebike.com, Google images
Image 2, Mountain Flyer, 11/19/2010
Image 3, Google images

Sunday, August 26, 2012

X-rays, CT's and MRI's, Understanding the Differences & Kona 2012 Tips

"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


An old 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?"
__________________________________________________

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.
Computed Tomography (CT)
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.

Kona Tips, 42 Days
Pacific Vibrations in downtown Kona is the home to the counter culture Underpants Run, a must do "run" Thursday morning of race race week.   Well, it's more of a walk-jog-jumping jacks than anything else but most of all, it's terrific fun. Bring your camera for sure.  The proceeds benefit a local charity and I wouldn't be surprised if it were over $20,000.  The "uniform" is tighty whiteys, knee high black socks, HR monitor strap and a "bad hat," or some costume variation there of. Here's a view of 2011.





Image 1, Google Images

Thursday, August 23, 2012

Knee Injections - Platelet Rich Plasma Update & Kona Tips for 2012


"Kobe Bryant Tries New Therapy

Los Angeles Lakers guard Kobe Bryant underwent an experimental but increasingly popular procedure last month in Germany in an attempt to help heal his oft-injured right knee.......  The procedure, called platelet rich plasma therapy...."                     ESPNLosAngeles.com, 7/1/2011


Joint injections in the triathlete have been covered here a number of times:
"Cortisone Shots, the Good, the Bad and the Ugly"  2/5/2011
"ESI's, Back Injections"  10/13/2011
"Injections for Triathletes, What You Need to Know"  4/8/2012

The 2/5/2011 piece pretty much covered what goes in there and why.  A recent article in Arthroscopy  magazine from Spain by Eduardo Anitua, MD et. al. studied two groups of people with knee injections, one with viscosupplementation, three injections of a hyaluronic acid medication on a weekly basis, and the second with a PRP preparation (PRGF-Endoret), not unlike that injected into Kobe.  In each case, blood is withdrawn from the subject, spun down in a centrifuge to separate the specific components of the blood, and then only a small portion of that sample selected for re-injection into the subjects painful knee.

So many of us incorrectly assume that when we're discussing arthritis that we're only referring to those of us with white hair and a cane.  Not so.  If you look at the triathlon population who's undergone arthroscopy for a torn meniscus, anyone who's ruptured their ACL or PCL, had prior fracture around the knee or simply knee trauma, you're looking at a large group with the potential for early degenerative change.

                                   

The primary outcome measure was a reduction in pain by at least 50% by 24 weeks post injection.  They also assessed stiffness and physical function.  The PRP showed "superior results when compared to the hyaluronic acid...with  comparable safety profile in alleviating symptoms of mild to moderate osteoarthritis of the knee."

So what does this mean to you? Plenty.  PRP is not widely accepted yet, nor widely paid for yet by insurance companies, but it show significant promise for the future.  Your future.  As more data is collected over the upcoming years, this may turn out to just one more tool in the armamentarium of the medical team to keep you training and racing despite pain due to arthritis of the knee.                                                                 

Kona Tips 2012

I don't think that buying a special aero helmet for this race, if you don't have one is required.  Also, it's pretty hot , as you know, and a simple addition to your training helmet is quite sufficient.  If you look carefully, you'll see the owner of this helmet has used common clear packing tape, and a little black electrician's tape to block the wind over just the front half f this helmet.  This leaves the rear half open for ventilation.  I talked with aero guru John Cobb about this concept at a bike fit a few years ago and he'd actually wind tunnel tested this concept giving it excellent marks.

Clear packing tape over forward vent holes only.

Images 1,2 Google images

Wednesday, August 22, 2012

Hip Arthroscopy, Post Op Pain Control, Kona Tips 2012



"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's Earth Band


No one likes to be told that the next step in their care is surgery.  This is no more true than when it's hip or back surgery. But the diagnosis and treatment of hip joint pathology has taken a dramatic leap over the past decade or so.  Consider the early days of hip arthroscopy when it was considered a triumph just to be able to get the scope into the joint!  Needless to say the goals in 2012 are accurate assessment and successful treatment of disease processes.

Since the hip area is large, and the source of pain can be both from within the joint or referred from another body part like the lumbar spine, diagnosis, accurate diagnosis that is, can sometimes present a real problem.

So, let's say your doc thinks you might have what's called FAI, or femeroacetabular impingement, one of the most common reasons hips are scoped.

It is not known how many people may have FAI.  Some people may live long, active lives with FAI and never have problems.  When symptoms develop, however, it usually indicates that there's damage to the cartilage or labrum and the disease is likely to progress.  Symptoms may include pain, stiffness, and limping. 



FAI occurs because the hip bones do not form normally during the childhood growing years. It is the deformity of a bone spur, pincer bone spur, or both, that leads to joint damage and pain. When the hip bones are shaped abnormally, there is little that can be done to prevent FAI.  Because athletically active people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active. However, exercise does not cause FAI.

One note.  Pain following surgery can be a real bugger. People think that just because it's an arthroscopic procedure and the holes quite small that it won't hurt.  Not so.  In fact, with respect to hip scopes, a recent study in Arthroscopy magazine by Thomas Youm, MD, et. al., showed that those patients who had a femoral nerve block, as opposed to tradtional intravenous pain medication, were "significantly more likely to be satisfied with their post operative pain control....."   So, when signing on the dotted line for surgery, any type of surgery actually, you would do well to discuss the plan for pain control after the procedure.  In detail.

Hopefully, when your recovery is complete, and you don't have damage to the joint itself, you'll be a better athlete/dancer than Crocodile Dundee. ("Up North in the Never-Never, where the land is harsh and bare, lives a mighty hunter named Mick Dundee who can dance like Fred Astaire.")
________________________________________________

Taking Coumadin?  Need an injection?  We've seen for years, patients who will have a musculoskeletal problem like hip bursitis, arthritis, joint swelling, biceps tendinitis to name a few, and they'll present for an injection.  The question has always been whether or not to perform the procedure in light of the fact that their blood has been "thinned" with the Coumadin. An article by Diehl, et. al. in the 8/2012 issue of Practical Pain Management would say that unless there's some contraindication like cellulitis, poorly controlled anticoagulation levels, joint prosthesis, (possibly) pregancy, etc., to proceed with the injection as you would in any other patient.
________________________________________________

Kona Tips....  45 days

The Boy Scouts motto is "Be Prepared."  Whether 2012 will be your first visit to the quiet fishing village of Kailua-Kona or you've been there many times, prepare your ride, prepare your support crew, prepare yourself.  Go to the bike turn around in Hawi, go to the run turn around in Keauhou, understand the course as best you can.




The ART tent will be nearby all week and if you've heard about it but never tried it, have a shot.  Who doesn't have something that hurts.  And you don't need to be in the race.  I had a treatment from a Kona based Chiropractor there last year and it was most enlightening.

 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.

 After you finish, and get your medal and something to eat, and you realize you're not going to die...when they take you to the massage tent and ask if they can help you, don't say no. Get a 5 minute foot massage. It's to die for. And besides, you earned it.

Monday, August 20, 2012

Separated Shoulders, Hard to Fix plus Kona 2012 Tips

"He who will not risk will not win." John Paul Jones

















A fan photographing triathletes on the pier in Kona.




 How often have we been watching a bike race, a draft legal tri, or the Tour de France and we witness a big bike crash?  Somebody goes down hard....and does not get up?  The camera pans over to the injured athlete cradling one arm with the other, and the announcer says something like, "That looks like the dreaded collar bone position to me."  And they're usually right.




I've written about fractures of the clavicle, the collar bone, frequently in the past but today it's what happens at the far end of the collar bone, the shoulder separation or acromioclavicular (A/C) separation which draws our attention.  It's pretty simple to imagine the biker who is headed to the ground and suffers a blow to the shoulder of significant magnitude to cause this type of injury pattern.



 




                                    




 


The ligaments at the far end of the clavicle are torn to a degree, some worse than others, and in the more severe injuries, the end of the clavicle becomes quite prominent.  There's a big bump over the end of the shoulder.  Should this be the case, one of the recommended possibilities will likely be arthroscopic reconstruction of the joint, possibly using surgical hardware and/or tissue from the tissue and bone bank.



This is  an important concept to understand as an occasional bad actor in the tissue harvesting arena gives the whole business a bad rep.  As you know, we implant all kinds of things in our bodies surgically that used to belong to someone else.  A good example is blood.  I'm on a first name basis with the folks at the local blood bank as I donated my 108th unit of blood this year.  Blood products are used in so many ways be it to help resussitate trauma patients to those with hemophilia.  The same is true of other body parts needed for ACL knee reconstruction, eye surgery, total joint replacement, and in this case a reconstruction of the acromio-clavicular joint.



In the not too distant past, a number of large screws, braces, Gortex straps, etc. were designed to hold the joint in place and none worked very well.  Currently, the use of small threaded screws, buttons and "allograft" (from another human) tendon tissue work quite nicely to restore the relationships of the A/C joint.  A recent article in the Journal of Bone and Joint Surgery (Sobhy, April 23, 2012) looked at repairing this injury with nylon tape and no hardware. After a minimum of 28 months, the authors noted a reduction of the displacement from an average of 13 mm down to 2mm, 88% satisfaction, and a low complication rate. After a period of early rehab, patients are returned to weight training at about 3 months post op, and sports requiring contact like lacrosse or football by 6 months.  It's a good operation which seems to solve the problem and one that I feel will stand the test of time.  Keep it in your back pocket, just in case.


 Kona Tips for 2012.....41 days







Bike covers are not allowed after you rack your bike the afternoon before the race.  If you fear overnight rain, do as this competitor did and put an old swim cap on the saddle.  In the morning, after body marking, when you get access to your steed, drop the cap in your pre-swim bike and continue with your race preparation.



Where else but Kona can you go for a training swim a few days before the race and swim up to a coffee barge?  The good folks of Coffees of Hawaii do this for everyone in the water, not just the competitors, Tuesday through Friday during race week.  And it's hot!  And good.  Make sure you buy some of their product when back on dry land.




 Lastly, with regard to crossing the Kona finish line, to quote 3 Doors Down from  Kryptonite, "If I'm alive  at the end, will you still be there to hold my hand?"


 














You on the jumbo tron at the Kona finish line.  YES!



 


Image 2, 4 Google Images





Sunday, August 19, 2012

Separated Shoulders, Hard to Fix, Plus Kona Tips 2012

"He who will not risk will not win."  John Paul Jones
A fan photographing triathletes on the pier in Kona.

How often have we been watching a bike race, a draft legal tri, or the Tour de France and we witness a big bike crash?  Somebody goes down hard....and does not get up?  The camera pans over to the injured athlete cradling one arm with the other, and the announcer says something like, "That looks like the dreaded collar bone position to me."  And they're usually right.

I've written about fractures of the clavicle, the collar bone, frequently in the past but today it's what happens at the far end of the collar bone, the shoulder separation or acromioclavicular (A/C) separation which draws our attention.  It's pretty simple to imagine the biker who is headed to the ground and suffers a blow to the shoulder of significant magnitude to cause this type of injury pattern.

                                     

The ligaments at the far end of the clavicle are torn to a degree, some worse than others, and in the more severe injuries, the end of the clavicle becomes quite prominent.  There's a big bump over the end of the shoulder.  Should this be the case, one of the recommended possibilities will likely be arthroscopic reconstruction of the joint, possibly using surgical hardware and/or tissue from the tissue and bone bank.

       This is  an important concept to understand as an occasional bad actor in the tissue harvesting arena gives the whole business a bad rep.  As you know, we implant all kinds of things in our bodies surgically that used to belong to someone else.  A good example is blood.  I'm on a first name basis with the folks at the local blood bank as I donated my 108th unit of blood this year.  Blood products are used in so many ways be it to help resussitate trauma patients to those with hemophilia.  The same is true of other body parts needed for ACL knee reconstruction, eye surgery, total joint replacement, and in this case a reconstruction of the acromio-clavicular joint.

In the not too distant past, a number of large screws, braces, Gortex straps, etc. were designed to hold the joint in place and none worked very well.  Currently, the use of small threaded screws, buttons and "allograft" (from another human) tendon tissue work quite nicely to restore the relationships of the A/C joint.  A recent article in the Journal of Bone and Joint Surgery (Sobhy, April 23, 2012) looked at repairing this injury with nylon tape and no hardware. After a minimum of 28 months, the authors noted a reduction of the displacement from an average of 13 mm down to 2mm, 88% satisfaction, and a low complication rate. After a period of early rehab, patients are returned to weight training at about 3 months post op, and sports requiring contact like lacrosse or football by 6 months.  It's a good operation which seems to solve the problem and one that I feel will stand the test of time.  Keep it in your back pocket, just in case.

                                        



Kona Tips for 2012.....41 days 



Bike covers are not allowed after you rack your bike the afternoon before the race.  If you fear overnight rain, do as this competitor did and put an old swim cap on the saddle.  In the morning, after body marking, when you get access to your steed, drop the cap in your pre-swim bike and continue with your race preparation.

Where else but Kona can you go for a training swim a few days before the race and swim up to a coffee barge?  The good folks of Coffees of Hawaii do this for everyone in the water, not just the competitors, Tuesday through Friday during race week.  And it's hot!  And good.  Make sure you buy some of their product when back on dry land.



Lastly, with regard to crossing the Kona finish line, to quote 3 Doors Down from  Kryptonite, "If I'm alive  at the end, will you still be there to hold my hand?"

You on the jumbo tron at the Kona finish line.  YES! 



 Image 2, 4 Google Images

Wednesday, August 15, 2012

Precision vs Accuracy: A case for Common Sense & Kona Tips


"I read it on the internet, so it must be true."


In other words, don't believe everything you read.  Here, or anywhere. (Although I do strive for accuracy in these writings.

I belong to the Arthroscopy Association of North America, ANNA, and in this month's Journal is an editorial by Gary Poehling, MD et al, which speaks to this phenomenon that I'll partially repeat.  We have so many "experts", web sites, mags, blogs and tweets which purport to tell what we should do to improve/get faster/lead better lives, that we need to remain vigilant as to the source, veracity, and reliability of the information we take in.  In triathlon, bogus information may simply alter performance.  In medicine, or your work, faulty or inaccurate communication could have a much more significant consequence.
______________________________________________________________

"Mark Twain once said, “Facts are stubborn, but statistics are more pliable.”1
In an ever more technologically driven society, we strive for endless precision. The written word often carries unwarranted credence simply because it is written, or precise. Surely the phrase, “I read it on the Internet, so it must be true,” sounds familiar. (It should … a Google search of that quote alone yielded 864 million hits in 0.17 seconds.) Likewise, data with clever statistical tweaks can be guilty of the same problem. What researchers and clinicians should strive to discover, on the other hand, is its accuracy—how true it is.
Little has changed in the scientific method since the time of Aristotle, but much has changed in the ability to detect differences. We now have computing power nearly the size of a Cray computer in the palms of our hands. Recall the size of a hard drive in the early 1990s with 2 Megabytes being almost the size of a toaster. Now a typical thumb drive can carry over 8 Gigabytes, or 8,000 Megabytes, of data.

Technology provides us with the ability to calculate data points to the nth decimal. The clinical significance of that datum may be several decimal points to the left, or perhaps, even a whole integer.


Fortunately, we recognize that tremendous progress has been made from the days when “might made right.” We have shied away from expert opinion and veered dramatically toward higher levels of evidence. Terms like prospective, randomized, controlled, blinding, a priori power analysis, narrow confidence interval, outcome measure, and systemic review, appear regularly in most study reports. Most importantly, you, the reader, possess an uncanny ability to separate the wheat from the chaff.
In the future, newer tools will evolve to help us. Perhaps outcome measures, for example, can be standardized and updatable. In the meantime, we must keep our eye on the ball as we will be challenged to produce clinically accurate conclusions with the exponential increase in technology. As Gertrude Stein said, “Everybody gets so much information all day long that they lose their common sense.” Precisely … ."

Gary G. Poehling, MD

Heading West to Kona

Craig Alexander, pre-dawn hours of the transition area in Kona
As you can see by the above photo, it's still night when the transition area opens in Kona on race morning.  While the location of the pros bikes may be well lit, this is not the case for all of the age groupers.  There are a number of flashlights manned by the race volunteers but the thinking triathlete simply remembers to pack a camping/trail running style head lamp for this function.  After use, it's left in the pre-swim bag and retrieved at race's end.

Many athletes see this visit to the Big Island as a time to buy gifts for family and friends, a sort of pay back if you will.  It is incredibly easy to disregard this increase in ones baggage until packing for home and the weight of your bag far exceeds the airline limit.  I, personally have had the privilege of compensating the airline $125 for this grievous act.  Why not plan on bringing pre-addressed 9"X12" manila envelopes, add a copy of the race program and a flat box of chocolate covered macadamia nuts, and drop them in the mail?  The post office is 3 blocks from the start/finish line of the race.

Image 1 Google Images

Precision vs Accuracy: A Case For Common Sense, plus Kona Tips


"I read it on the internet, so it must be true."



 







In other words, don't believe everything you read.  Here, or anywhere. (Although I do strive for accuracy in these writings.




 I belong to the Arthroscopy Association of North America, ANNA, and in this month's Journal is an editorial by Gary Poehling, MD et al, which speaks to this phenomenon that I'll partially repeat.  We have so many "experts", web sites, mags, blogs and tweets which purport to tell what we should do to improve/get faster/lead better lives, that we need to remain vigilant as to the source, veracity, and reliability of the information we take in.  In triathlon, bogus information may simply alter performance.  In medicine, or your work, faulty or inaccurate communication could have a much more significant consequence.




______________________________________________________________




 "Mark Twain once said, “Facts are stubborn, but statistics are more pliable.”1




In an ever more technologically driven society, we strive for endless precision. The written word often carries unwarranted credence simply because it is written, or precise. Surely the phrase, “I read it on the Internet, so it must be true,” sounds familiar. (It should … a Google search of that quote alone yielded 864 million hits in 0.17 seconds.) Likewise, data with clever statistical tweaks can be guilty of the same problem. What researchers and clinicians should strive to discover, on the other hand, is its accuracy—how true it is.




Little has changed in the scientific method since the time of Aristotle, but much has changed in the ability to detect differences. We now have computing power nearly the size of a Cray computer in the palms of our hands. Recall the size of a hard drive in the early 1990s with 2 Megabytes being almost the size of a toaster. Now a typical thumb drive can carry over 8 Gigabytes, or 8,000 Megabytes, of data.


Technology provides us with the ability to calculate data points to the nth decimal. The clinical significance of that datum may be several decimal points to the left, or perhaps, even a whole integer.


Fortunately, we recognize that tremendous progress has been made from the days when “might made right.” We have shied away from expert opinion and veered dramatically toward higher levels of evidence. Terms like prospective, randomized, controlled, blinding, a priori power analysis, narrow confidence interval, outcome measure, and systemic review, appear regularly in most study reports. Most importantly, you, the reader, possess an uncanny ability to separate the wheat from the chaff.



In the future, newer tools will evolve to help us. Perhaps outcome measures, for example, can be standardized and updatable. In the meantime, we must keep our eye on the ball as we will be challenged to produce clinically accurate conclusions with the exponential increase in technology. As Gertrude Stein said, “Everybody gets so much information all day long that they lose their common sense.” Precisely … ."




Gary G. Poehling, MD


Heading West to Kona














Craig Alexander, pre-dawn hours of the transition area in Kona




As you can see by the above photo, it's still night when the transition area opens in Kona on race morning.  While the location of the pros bikes may be well lit, this is not the case for all of the age groupers.  There are a number of flashlights manned by the race volunteers but the thinking triathlete simply remembers to pack a camping/trail running style head lamp for this function.  After use, it's left in the pre-swim bag and retrieved at race's end.




Many athletes see this visit to the Big Island as a time to buy gifts for family and friends, a sort of pay back if you will.  It is incredibly easy to disregard this increase in ones baggage until packing for home and the weight of your bag far exceeds the airline limit.  I, personally have had the privilege of compensating the airline $125 for this grievous act.  Why not plan on bringing pre-addressed 9"X12" manila envelopes, add a copy of the race program and a flat box of chocolate covered macadamia nuts, and drop them in the mail?  The post office is 3 blocks from the start/finish line of the race.





Image 1 Google Images



 



Tuesday, August 14, 2012

Heal That Broken Bone in a Jif




"He headed west 'cause he felt that a change would do him good."


 


                                                                                      Bob Seger


 



 Heading west? Like to Hawaii? The Ironman World Championship is in just 54 days!  For those of you heading to the Big Island this year, a portion of each of the upcoming blogs will be devoted to making your stay there a little easier.  So here goes:


 1.  Ain't no one happy 'less Mama's happy.  If you're racing, and a might distracted, make sure the family is a part of the picture.  Volunteering for the race is a must.  Work an aid station outside your condo, be an athlete escort on Friday on the pier.  They'll thank you for it.


_________________________________


 So many of us including big names like Jordan Rapp, Frank Schleck, and Lance Armstrong to name a few have suffered a fracture, a broken bone, during training. These possess a significant potential to really slow us down.  Many triathletes take the attitude that that says, "I'll just keep going regardless," possibly putting ultimate healing in jeopardy.  But, if you follow these few recommendations you'll be more likely to have a good result.


 1. Talk with your doctor, understand what your options are, surgical and non-surgical, what his/her experience is with both methods of treating your exact fracture.  For example, with collarbone fractures, the adage used to be "if both ends of the fracture are in the same room it will heal."  But, with time have come various plating options that may far out pace non surgical care in 2012.



 2.  Consume a normal balanced diet maintaining adequate nutrition levels to ensure the body has the appropriate vitamins and minerals to provide a positive healing environment.


 3.  Calcium, enough but not too much.  We used to think the more calcium the better, but no longer.  When excess calcium is consumed, in susceptible individuals kidney stones may form.  Also, there are a number of studies that are beginning to show a relationship between too much calcium and increasing plaque forming in one's coronary arteries increasing the risk of a heart attack.  So, as above, a well balanced diet which includes adequate sources of calcium to at least meet the minimum daily requirement of 1200 mg/day is recommended.


 4.  Smoking cessation - if you smoke, stop.  There's clear evidence that those who smoke have prolonged fracture healing times.



It's also been shown that in some cases, a failure of consolidation of the fracture known as a nonunion is more likely in the smoking population.


 5.  Do what you're told.  Just the way we started this piece.  If you're asked not to run, or to pool run only, there must be a good reason behind it.  If you want to know why, ask. How long?  Ask. It will be easier to comply if you understand why.


 Lastly, the healing time from bone to bone varies wildly from say 3-4 weeks for a non displaced rib fracture to months for certain foot bones.  Do your best to avoid injury, but if you end up with a broken bone, do your part and you'll have the highest likelihood of success and return to the sport you love.


 



Images 2 and 4, Google Images


 



Monday, August 13, 2012

Mend That Broken Bone in a Jif


                                                                            



"He headed west 'cause he felt that a change would do him good."

                                                                                      Bob Seger


Heading west? Like to Hawaii? The Ironman World Championship is in just 54 days!  For those of you heading to the Big Island this year, a portion of each of the upcoming blogs will be devoted to making your stay there a little easier.  So here goes:

1.  Ain't no one happy 'less Mama's happy.  If you're racing, and a might distracted, make sure the family is a part of the picture.  Volunteering for the race is a must.  Work an aid station outside your condo, be an athlete escort on Friday on the pier.  They'll thank you for it.
_________________________________

So many of us including big names like Jordan Rapp, Frank Schleck, and Lance Armstrong to name a few have suffered a fracture, a broken bone, during training. These possess a significant potential to really slow us down.  Many triathletes take the attitude that that says, "I'll just keep going regardless," possibly putting ultimate healing in jeopardy.  But, if you follow these few recommendations you'll be more likely to have a good result.

1. Talk with your doctor, understand what your options are, surgical and non-surgical, what his/her experience is with both methods of treating your exact fracture.  For example, with collarbone fractures, the adage used to be "if both ends of the fracture are in the same room it will heal."  But, with time have come various plating options that may far out pace non surgical care in 2012.


2.  Consume a normal balanced diet maintaining adequate nutrition levels to ensure the body has the appropriate vitamins and minerals to provide a positive healing environment.

3.  Calcium, enough but not too much.  We used to think the more calcium the better, but no longer.  When excess calcium is consumed, in susceptible individuals kidney stones may form.  Also, there are a number of studies that are beginning to show a relationship between too much calcium and increasing plaque forming in one's coronary arteries increasing the risk of a heart attack.  So, as above, a well balanced diet which includes
adequate sources of calcium to at least meet the minimum daily requirement of 1200 mg/day is recommended.

4.  Smoking cessation - if you smoke, stop.  There's clear evidence that those who smoke have prolonged fracture healing times.

It's also been shown that in some cases, a failure of consolidation of the fracture known as a nonunion is more likely in the smoking population.

5.  Do what you're told.  Just the way we started this piece.  If you're asked not to run, or to pool run only, there must be a good reason behind it.  If you want to know why, ask. How long?  Ask. It will be easier to comply if you understand why.

Lastly, the healing time from bone to bone varies wildly from say 3-4 weeks for a non displaced rib fracture to months for certain foot bones.  Do your best to avoid injury, but if you end up with a broken bone, do your part and you'll have the highest likelihood of success and return to the sport you love.



Images 2, 4 Google Images

Thursday, August 9, 2012

Triathletes and Blood Donation

Should Triathletes Give Blood?



"For every complex problem, there is an uncomplicated answer; neat, simple and wrong." H.L. Menken

HuliSue's is a terrific barbecue place in Kamuela, HI when you find yourself north of Kona some day. If you ordered a beef sandwich, you'd get plenty of iron to help make red blood cells. Ah, but then what do you do with those red cells? Keep 'em? Donate a few to someone who might really need them?

Well, I'm prejudiced. I recently donated my 106th unit of blood to Virginia Blood Services, our local purveyor of blood products recently. If you realize that when a "pint" of blood comes out of your veins, only about a third of it is blood cells, the other two thirds being plasma. Plasma, the fluid portion will be replaced in a couple hours but it will take your bone marrow 3 or more weeks to restore the RBC's. Each person's reaction is different, and changes from donation to donation. One may have to reduce the intensity of work outs for a short time, and probably would cease donations a month to 6 weeks before an important race, or the racing season in general. That said, platelet need is always in season, requires no loss of red cells (or oxygen carrying capacity), and can be done virtually any time in the year.

There are lots of reasons not to give blood...a needle stick, a few days of non-maximal training, rumors from the uninformed, etc. But, there's never an over abundance of blood, it's needed for patients getting dialysis, heart surgery, cancer and trauma victims, etc. Heck, even Lance might have needed a transfusion following his orchiectomy and subsequent chemo.

Lastly, who among you hasn't had a bike crash? One day, the need might be yours. 
 
So, summer can be a rough time for blood banks since their regular donors are often on vacation or keeping irregular schedules.  If you want a good feeling of doing something to benefit others, drop by your local blood bank today.  You'll be glad you did.

Triathletes and Blood Donation

Should  Triathletes Give Blood?




 "For every complex problem, there is  an uncomplicated answer; neat, simple and wrong." H.L.  Menken


 HuliSue's is a terrific barbecue place in  Kamuela, HI when you find yourself north of Kona some day. If you ordered a beef  sandwich, you'd get plenty of iron to help make red blood cells. Ah, but then  what do you do with those red cells? Keep 'em? Donate a few to someone who might  really need them?


 Well, I'm prejudiced. I recently donated my 106th unit  of blood to Virginia Blood Services, our local purveyor of blood products recently. If you realize that when a "pint" of blood comes out  of your veins, only about a third of it is blood cells, the other two thirds  being plasma. Plasma, the fluid portion will be replaced in a couple hours but it will  take your bone marrow 3 or more weeks to restore the RBC's. Each person's  reaction is different, and changes from donation to donation. One may have to  reduce the intensity of work outs for a short time, and probably would cease  donations a month to 6 weeks before an important race, or the racing season in  general. That said, platelet need is always in season, requires no loss of red  cells (or oxygen carrying capacity), and can be done virtually any time in the  year.


 There are lots of reasons not to give blood...a needle stick, a few  days of non-maximal training, rumors from the uninformed, etc. But, there's  never an over abundance of blood, it's needed for patients getting dialysis,  heart surgery, cancer and trauma victims, etc. Heck, even Lance might have  needed a transfusion following his orchiectomy and subsequent  chemo.


 Lastly, who among you hasn't had a bike crash? One day, the need  might be yours. 




 So, summer can be a rough time for blood banks since their regular donors are often on vacation or keeping irregular schedules.  If you want a good feeling of doing something to benefit others, drop by your local blood bank today.  You'll be glad you did.




Sunday, August 5, 2012

Sodium Loading, Will it Improve Your Performance?

"Water, water everywhere, nor any drop to drink."
                                         Rime of the Ancient Mariner

Clever Hydration System



As an Injured Triathlete, Will the New Health Care Law Affect you? Yes.


The new Health care law, so called Obama Care, is so voluminous that few among us understand it completely.  This would likely include those in Congress who voted for or against it. On a more personal level, I for one cannot predict how it might change our lives specifically.  But, for comparison, the Massachusetts Health Care Reform Act of 2006 is frequently used as a starting point.  As you’d expect, the Democrats will focus on the similarities between the two laws and Republicans the differences.  I can give you a few specifics as triathletes that you would want to be aware of, both in my specialty Orthopedic Surgery, as well as Primary Care.



According to the American Academy of Orthopedic Surgeons, the Massachusetts law extended health care coverage to an additional 400,000 state residents bringing the state up to 98.1% insured, the highest in the nation.  One negative to this is that physicians reported that an average wait time for consultation with the orthopedist/sports doc rose from 17 days to 26 days.  Patients who were previously uninsured often have a longer list of problems and comorbidities that need to be addressed, increasing the strain on already limited resources in both private practices and hospital settings.  Additionally, health care reform has caused a shortage of Primary Care physicians making it more difficult for orthopedic patients to receive follow-up treatment at local primary care facilities.  Nearly one in five non-elderly adults in Massachusetts is unable to find a Primary Care physician.  Add to this the fact that although over 50% of current medical students are female, less than 10% of practicing Orthopedic Surgeons are female.  As they say in Apollo 13, “Houston, we have a problem.”



Stay tuned as we as a nation continue to try to come to grips with this formidable problem.



Fluid and Electrolytes in Triathletes



Want to rile up a group of triathletes?  Tell them you have the definitive answer regarding the management of what goes in their mouths during training and racing for optimum performance.  We vary widely from the camp that preaches “drink according to thirst” to those with some variety of prescribed volume and make up of their replacement beverage.  Everyone has a say.  And, given the size of the triathlon market, the stakes can be pretty high.  I certainly don’t claim to know more than the next guy, but Bob Seebohar*, one of the first USAT Level III Elite Coaches, and RD, has an opinion.  “No matter whom you believe or what theory you subscribe to, for better performance, triathletes need to consume electrolytes.”**



Bob points out, for example, that the human body is very good as sodium regulation.  Understanding that while we may have a diet low in sodium, or one where the salt shaker is never far away the body can maintain a sodium balance or homeostasis.  Basically, it’s sodium in equals sodium out through sweat and bodily functions.  He goes on to point out that "scientific research suggests acute sodium loading the night before and/or the morning of a competition can be beneficial in improving better fluid balance and acclimating to warm environments.”**



He mentions that this should not be attempted more than two days before one’s event secondary to the potential for gaining weight and bloating.  And, if the athlete has experienced difficulties staying hydrated, “combining acute sodium loading prior to competition with a low sodium diet may help.”**  As with any change, trying it a few times before quality training sessions makes sense.   If you have questions, Bob can be reached at coachbob@fuel4mance.com  or visit www.fuel4mance.com.


*     Bob Seebohar was also my USAT Instructor at a USAT Coaching Certification Course

**  USA Triathlon Magazine, Summer 2012





Sodium Loading, Will it Help Your Performance?

"Water, water everywhere, nor any drop to drink."


                                         Rime of the Ancient Mariner


  DSCN5905














 



 


 As an Injured Triathlete, Will the New Health Care Law Affect you? Yes.


 



 The new Health care law, so called Obama Care, is so voluminous that few among us understand it completely.  This would likely include those in Congress who voted for or against it. On a more personal level, I for one cannot predict how it might change our lives specifically. But, for comparison, the Massachusetts Health Care Reform Act of 2006 is frequently used as a starting point.  As you’d expect, the Democrats will focus on the similarities between the two laws and Republicans the differences.  I can give you a few specifics as triathletes that you would want to be aware of, both in my specialty Orthopedic Surgery, as well as Primary Care.



 According to the American Academy of Orthopedic Surgeons, the Massachusetts law extended health care coverage to an additional 400,000 state residents bringing the state up to 98.1% insured, the highest in the nation.  One negative to this is that physicians reported that an average wait time for consultation with the orthopedist/sports doc rose from 17 days to 26 days.  Patients who were previously uninsured often have a longer list of problems and comorbidities that need to be addressed, increasing the strain on already limited resources in both private practices and hospital settings.  Additionally, health care reform has caused a shortage of Primary Care physicians making it more difficult for orthopedic patients to receive follow-up treatment at local primary care facilities.  Nearly one in five non-elderly adults in Massachusetts is unable to find a Primary Care physician. Add to this the fact that although over 50% of current medical students are female, less than 10% of practicing Orthopedic Surgeons are female.  As they say in Apollo 13, “Houston, we have a problem.”


 



 Stay tuned as we as a nation continue to try to come to grips with this formidable problem.



 



 Fluid and Electrolytes in Triathletes



 Want to rile up a group of triathletes?  Tell them you have the definitive answer regarding the management of what goes in their mouths during training and racing for optimum performance.  We vary widely from the camp that preaches “drink according to thirst” to those with some variety of prescribed volume and make up of their replacement beverage.  Everyone has a say.  And, given the size of the triathlon market, the stakes can be pretty high.  I certainly don’t claim to know more than the next guy, but Bob Seebohar*, one of the first USAT Level III Elite Coaches, and RD, has an opinion.  “No matter whom you believe or what theory you subscribe to, for better performance, triathletes need to consume electrolytes.”**


 Bob points out, for example, that the human body is very good as sodium regulation.  Understanding that while we may have a diet low in sodium, or one where the salt shaker is never far away the body can maintain a sodium balance or homeostasis.  Basically, it’s sodium in equals sodium out through sweat and bodily functions.  He goes on to point out that "scientific research suggests acute sodium loading the night before and/or the morning of a competition can be beneficial in improving better fluid balance and acclimating to warm environments.”**


 He mentions that this should not be attempted more than two days before one’s event secondary to the potential for gaining weight and bloating.  And, if the athlete has experienced difficulties staying hydrated, “combining acute sodium loading prior to competition with a low sodium diet may help.”** As with any change, trying it a few times before quality training sessions makes sense.  If you have questions, Bob can be reached at coachbob@fuel4mance.com  or visit www.fuel4mance.com.


 *    Bob Seebohar was also my USAT Instructor at a USAT Coaching Certification Course


 **  USA Triathlon Magazine, Summer 2012



DSCN5932