Monday, October 29, 2012

Triathletes Racing After Total Knee/Hip Replacement - Part Two



"The past is gone but something might be found to take its place."
                                                  Gin Blossoms, Hey Jealousy 


A pink bike. Something to do with that old steed. Home decoration.

Only In Hawaii

Kimo the dog. I wear glasses, but my eyesight's not all that bad. While treading water at the Coffees of Hawaii barge (every year during IM race week in Kona, the good folks at Coffees of Hawaii set up a large sailing craft about 700 m off shore, where anyone who swims up is offered a small cup of Kona's finest) I saw an odd looking "swimmer."

A group of three was approaching from a distance and the middle "swimmer" appeared to have a full face mask on...but with what looked like pointy ears.  As they closed in on the coffee barge, surprisingly the 3rd swimmer turned out to be Kimo, a German Shepard swimming with a life vest on.  He (she?) seemed quite happy dog paddling in the Pacific.  As if you needed to be reminded, things are different in Hawaii.  






Joint Replacement in Athletes

A recent quote from the The American Journal of Orthopedics, 2012:

"The October issue of The American Journal of Orthopedics features articles focused on hip and knee adult reconstruction surgical procedures. Today’s aging population is more active than ever. The original goals of pain relief with both hip and knee arthroplasty are no longer satisfactory in this population. These patients want to continue participating in more aggressive athletic and exercise programs that may prove detrimental to their implants."

I write this is response to a request I received recently from an athlete who'd received a new hip secondary to arthritis (like Floyd Landis) and wondered about this issue as;

"Sometimes a quality/enjoyment of life question? Race with modifications?"

It doesn't appear so. A joint replacement is a big hit.  It's an expensive undertaking and we're not yet at the point where the mechanical joint is as good as the one it replaces.  Be certain that we're improving all the time.  But there is still a certain number of cycles that one can expect, a finite longevity.  When the artificial joint has reached the end of it's usable life, revision surgery is far more than simply changing a tire. The required procedure has a higher level of difficulty, higher potential for complication, including infection, a possibly devastating complication.  It's probable that the second joint will not be as successful as the first and not last as long.

So, for our athlete of 2012, the answer from the orthopedic community following total hip or knee replacement is still to make activity choices that prolong the expected life of the prosthesis.  Most docs would tell you that running is not on that list.

Triathletes Racing After Total Hip/Knee - Part Two

"The past is gone but something might be found to take its place."


                                                  Gin Blossoms, Hey Jealousy 


 


 














A pink bike. Something to do with that old steed. Home decoration.



 Only In Hawaii



Kimo the dog. I wear glasses, but my eyesight's not all that bad. While treading water at the Coffees of Hawaii barge (every year during IM race week in Kona, the good folks at Coffees of Hawaii set up a large sailing craft about 700 m off shore, where anyone who swims up is offered a small cup of Kona's finest) I saw an odd looking "swimmer."


A group of three was approaching from a distance and the middle "swimmer" appeared to have a full face mask on...but with what looked like pointy ears.  As they closed in on the coffee barge, surprisingly the 3rd swimmer turned out to be Kimo, a German Shepard swimming with a life vest on.  He (she?) seemed quite happy dog paddling in the Pacific.  As if you needed to be reminded, things are different in Hawaii.  






 


Joint Replacement in Athletes


A recent quote from the The American Journal of Orthopedics, 2012:


 "The October issue of The American Journal of Orthopedics features articles focused on hip and knee adult reconstruction surgical procedures. Today’s aging population is more active than ever. The original goals of pain relief with both hip and knee arthroplasty are no longer satisfactory in this population. These patients want to continue participating in more aggressive athletic and exercise programs that may prove detrimental to their implants."


I write this is response to a request I received recently from an athlete who'd received a new hip secondary to arthritis (like Floyd Landis) and wondered about this issue as;



"Sometimes a quality/enjoyment of life question? Race with modifications?"



It doesn't appear so. A joint replacement is a big hit.  It's an expensive undertaking and we're not yet at the point where the mechanical joint is as good as the one it replaces.  Be certain that we're improving all the time.  But there is still a certain number of cycles that one can expect, a finite longevity.  When the artificial joint has reached the end of it's usable life, revision surgery is far more than simply changing a tire. The required procedure has a higher level of difficulty, higher potential for complication, including infection, a possibly devastating complication.  It's probable that the second joint will not be as successful as the first and not last as long.


So, for our athlete of 2012, the answer from the orthopedic community following total hip or knee replacement is still to make activity choices that prolong the expected life of the prosthesis.  Most docs would tell you that running is not on that list.



Concussions off the Bike, ACL News

ACL Reconstruction Follow Up

 In August, I did some reporting on ACL (Anterior Cruciate Ligament of the knee) tears. Reuters reported recently, in a study of Australians followed for over three years following their reconstructions, that "half of people who played sports competitively or just for fun don't perform as well as they used to." When narrowed down to those who played competitively pre-injury, only 91 of 196 returned to their competitive sport.

 While this is a single study, and review of many give a more representative picture, suffice it to say that tearing an ACL can be a serious injury.  Also recently reported was poor results in Division 1 athletes who had ACL reconstruction using allograft tissue, that used from the tissue bank from another donor.  In fact, the failure rate approached 50%.  So, if you find your self in this quagmire, the better educated you are, the more you are able to help the surgeon make the best decision for the correct way to proceed in your specific case, the higher likelihood you'll have to return to the sport you love.



 Concussions Off the Bike

 Who among us hasn't been on a group bike ride where there hasn't been a crash of some sort? If you were lucky, it was just a little road rash. If not, a portion of the injury could be a head injury. And this is true for helmeted cyclists as well. Not infrequently a concussion will occur and this has the potential for being a more serious injury than we may have previously thought. The October 10, 2011 Sports Illustrated has an article on the NHL which discusses the head injury to it's "most important star" Sidney Crosby. They are rededicating themselves to player protection, and we should too.

 But haven't we always had the culture of endurance over safety? Haven't we seen the films of the last 400m of IM Hawaii where Paula Newby-Fraser, the Queen of Kona is weaving down Hualalai Street like some kind of drunk when Karen Smyers sprints by? Or Chris Legh, or Wendy Ingraham and Sian Welch, as they weave uncontrollably toward the finish line? Maybe they've crossed a line of a different sort! In the mid 2000's, I had the slowest bike time of all 1700 competitors in Hawaii when I stopped to help a biker on the down hill from Hawi whose front wheel had hit one of the plastic highway road reflectors at just the wrong angle. POW! Instantaneous crash, broken helmet, closed head injury, you can guess the rest as we waited for rescue help together. In short, once a concussion is recognized, that athlete's day is done - they should not be allowed to resume their sport, triathlon included.

 Research is showing that healing of injured brain tissue requires sufficient nutrients and rest. If this isn't allowed to occur, then the potential for increased injury increases. Previously, injury severity scales left a great deal of interpretation to the examiner when deciding how serious the concussion really was. Now, especially in NCAA sports, if a player suffers a concussion of any magnitude, he or she is out of the game. No questions asked.

 So, as an athlete, how do you determine if your bike mate's had a concussion after that crash? Well, you're probably not a neurologist, but starting with an "index of suspicion," at least considering that it's possible helps. Was there a loss of consciousness, confusion, head or neck ache, blurred vision or anxiety? In an athletic contest like football, the athlete would be asked, "Who Scored last?" or "Where are we playing today?" Finally if the suspicion continues, the player would be checked for balance and coordination. Now, I'm not saying that every time somebody in your bike group goes down that you start this cascade. But what I am saying is, that as a friend of somebody who's had an accident and my not realize that they've suffered a head injury - and are not making the best of decisions - you need to take charge. Nice the injured rider into calling it a day, just because, and give them a ride home. Likely, a trip to the local ER just to be on the safe side would also work Then, maybe after all that, it gets to be Miller Time.


Monday, October 22, 2012

Concussions Off the Bike & ACL Tear News

ACL Reconstruction Follow Up


In August, I did some reporting on ACL (Anterior Cruciate Ligament of the knee) tears. Reuters reported recently, in a study of Australians followed for over three years following their reconstructions, that "half of people who played sports competitively or just for fun don't perform as well as they used to." When narrowed down to those who played competitively pre-injury, only 91 of 196 returned to their competitive sport.

While this is a single study, and review of many give a more representative picture, suffice it to say that tearing an ACL can be a serious injury.  Also recently reported was poor results in Division 1 athletes who had ACL reconstruction using allograft tissue, that used from the tissue bank from another donor.  In fact, the failure rate approached 50%.  So, if you find your self in this quagmire, the better educated you are, the more you are able to help the surgeon make the best decision for the correct way to proceed in your specific case, the higher likelihood you'll have to return to the sport you love.


Concussions Off the Bike

Who among us hasn't been on a group bike ride where there hasn't been a crash of some sort? If you were lucky, it was just a little road rash. If not, a portion of the injury could be a head injury. And this is true for helmeted cyclists as well. Not infrequently a concussion will occur and this has the potential for being a more serious injury than we may have previously thought. The October 10, 2011 Sports Illustrated has an article on the NHL which discusses the head injury to it's "most important star" Sidney Crosby. They are rededicating themselves to player protection, and we should too.

But haven't we always had the culture of endurance over safety? Haven't we seen the films of the last 400m of IM Hawaii where Paula Newby-Fraser, the Queen of Kona is weaving down Hualalai Street like some kind of drunk when Karen Smyers sprints by? Or Chris Legh, or Wendy Ingraham and Sian Welch, as they weave uncontrollably toward the finish line? Maybe they've crossed a line of a different sort! In the mid 2000's, I had the slowest bike time of all 1700 competitors in Hawaii when I stopped to help a biker on the down hill from Hawi whose front wheel had hit one of the plastic highway road reflectors at just the wrong angle. POW! Instantaneous crash, broken helmet, closed head injury, you can guess the rest as we waited for rescue help together. In short, once a concussion is recognized, that athlete's day is done - they should not be allowed to resume their sport, triathlon included.

Research is showing that healing of injured brain tissue requires sufficient nutrients and rest. If this isn't allowed to occur, then the potential for increased injury increases. Previously, injury severity scales left a great deal of interpretation to the examiner when deciding how serious the concussion really was. Now, especially in NCAA sports, if a player suffers a concussion of any magnitude, he or she is out of the game. No questions asked.

So, as an athlete, how do you determine if your bike mate's had a concussion after that crash? Well, you're probably not a neurologist, but starting with an "index of suspicion," at least considering that it's possible helps. Was there a loss of consciousness, confusion, head or neck ache, blurred vision or anxiety? In an athletic contest like football, the athlete would be asked, "Who Scored last?" or "Where are we playing today?" Finally if the suspicion continues, the player would be checked for balance and coordination. Now, I'm not saying that every time somebody in your bike group goes down that you start this cascade. But what I am saying is, that as a friend of somebody who's had an accident and my not realize that they've suffered a head injury - and are not making the best of decisions - you need to take charge. Nice the injured rider into calling it a day, just because, and give them a ride home. Likely, a trip to the local ER just to be on the safe side would also work Then, maybe after all that, it gets to be Miller Time.



Tuesday, October 16, 2012

The View Into Kailua Bay

Aa Na Maka O Na Aa
    The Sparkling Eyes of My Roots

 "Knowing your roots is knowing your way.  Our roots represent the path that our ancestors have taken and the choices that have been made that define and illuminate who we are today."  

                                                   Official Program, IRONMAN World Championship, 2012


Caffeinated swimmers head back to the pier.




One athlete surveys the horizon, still obscure with the just rising sun. “What the heck is that?” he wonders as he spies a vessel under sail, a few hundred meters off the tip of the pier.  It seems to be handing something to the swimmers.
In fact, this is the Coffee’s of Hawaii barge, some might say a crazy idea from a couple years ago (but, then again, this is Hawaii and they certainly think outside the box here.)  Now it’s really taken hold.  It’s a floating Starbucks.  But free.  Like the Underpants Run on Thursday, or breakfast at Lava Java, it’s one of the things that makes Ironman unique among athletic contests. All you have to do, race entrant or not,  is swim up to the side of the craft, place your order, “decaf Kona coffee, please,” and a 3-4 oz piping hot cup of Kona’s finest is in your hand while floating in the Pacific Ocean.  You gaze around at the other swimmers doing likewise, and at once a big laugh breaks out at the absurdity of this moment.  Like the t-shirt says, life is good. I agree.
A number of industry booths have popped up on the pier from goggles to supplements to energy drinks (Jen - potential for insertion of IM sponsors here) and they all seem well attended.
It’s a big day.  Race registration for many! For those first timers, when they sit down with the volunteer team, and a big bag of goodies, including their Ironman wrist band, their ticket to the starting line on Saturday, the excitement begins to build.  They’re told about the Ironman Parade of Nations, the Ironman village with over 50 vendors, and the E Komo Mai (Welcome) banquet for 6,000 on Thursday evening, it’s close to information overload for our happy athlete.
The volunteer train leaves the station today and only picks up speed from here. This race couldn’t exist if it weren’t for the thousands of people who give of themselves and their time.  One good example would be the Transition team led by David Huerta.  His team members come from CA, VA, Kona, and even as far away as Australia.  For the most part they pay their own way, leave their “day job” behind, all so that they can contribute to the success of this event.  And many have been doing it for 20 years or longer. I always encourage the triathletes to “say thank you to every volunteer and every police officer” as they are truly the backbone of Ironman.

                                                                                                              Thanks to TP

The View in Kailua Bay

Aa Na Maka O Na Aa


    The Sparkling Eyes of My Roots



 "Knowing your roots is knowing your way.  Our roots represent the path that our ancestors have taken and the choices that have been made that define and illuminate who we are today."  



                                                   Official Program, IRONMAN World Championship, 2012


 


 












Inline image 1



See caffeine sated swimmers as they depart.



 


 One athlete surveys the horizon, still obscure with the just rising sun. “What the heck is that?” he wonders as he spies a vessel under sail, a few hundred meters off the tip of the pier.  It seems to be handing something to the swimmers.



 In fact, this is the Coffee’s of Hawaii barge, some might say a crazy idea from a couple years ago (but, then again, this is Hawaii and they certainly think outside the box here.)  Now it’s really taken hold.  It’s a floating Starbucks.  But free.  Like the Underpants Run on Thursday, or breakfast at Lava Java, it’s one of the things that makes Ironman unique among athletic contests. All you have to do, race entrant or not,  is swim up to the side of the craft, place your order, “decaf Kona coffee, please,” and a 3-4 oz piping hot cup of Kona’s finest is in your hand while floating in the Pacific Ocean.  You gaze around at the other swimmers doing likewise, and at once a big laugh breaks out at the absurdity of this moment.  Like the t-shirt says, life is good. I agree.




 




A number of industry booths have popped up on the pier from goggles to supplements to energy drinks (Jen - potential for insertion of IM sponsors here) and they all seem well attended.




 It’s a big day.  Race registration for many! For those first timers, when they sit down with the volunteer team, and a big bag of goodies, including their Ironman wrist band, their ticket to the starting line on Saturday, the excitement begins to build.  They’re told about the Ironman Parade of Nations, the Ironman village with over 50 vendors, and the E Komo Mai (Welcome) banquet for 6,000 on Thursday evening, it’s close to information overload for our happy athlete.




 The volunteer train leaves the station today and only picks up speed from here. This race couldn’t exist if it weren’t for the thousands of people who give of themselves and their time.  One good example would be the Transition team led by David Huerta.  His team members come from CA, VA, Kona, and even as far away as Australia.  For the most part they pay their own way, leave their “day job” behind, all so that they can contribute to the success of this event.  And many have been doing it for 20 years or longer. I always encourage the triathletes to “say thank you to every volunteer and every police officer” as they are truly the backbone of Ironman.








                                                                                                              Thanks to TP




Tuesday, October 9, 2012

Don't Let Your Doctor Do This



They're Starting to Stir in Kona

This is Kailua bay, quiet, tranquil, with the Ironman 6 days away.


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

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

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

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

Before the action at the Kailua pier heats up, athletes are reminded to steer clear of the boat traffic.



Monday, October 8, 2012

Don't Let Your Doctor Do This

Kona is starting to stir.
















This is Kailua bay, quiet, tranquil, with the Ironman 6 days away.


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

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

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

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
















Before the action at the Kailua pier heats up, athletes are reminded to steer clear of the boat traffic.

















This is Kailua bay, quiet, tranquil, with the Ironman 6 days away.






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



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



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



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
















Before the action at the Kailua pier heats up, athletes are reminded to steer clear of the boat traffic.