Monday, June 30, 2014

Pain in the Knee, What if it's Arthritis? Microfracture

Safety Note - I saw a gent riding his bike down the street recently, no hands, texting on his cell phone, paying absolutely no attention to what he was doing or the cars coming up from behind.  You talk about a recipe for disaster!  I'm hoping this is never you.

Must be good to be number 1

"A man must know his destiny. if he does not recognize it, then he is lost. By this I mean, once, twice, or at the very most, three times, fate will reach out and tap a man on the shoulder. if he has the imagination, he will turn around and fate will point out to him what fork in the road he should take, if he has the guts, he will take it."   George Patton
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I've addressed knee pain before but since it's such a common problem that takes people to their medical care giver, let's go over where we are in 2014.  Like the e-mail from this athlete we'll call Tina.

Dr. Post, 
I recently had an MRI that indicated "full thickness chondral loss along the apex and medial facet measuring 0.8cm in dimension -focal severe patellar chondrosis. The initial injury occurred in a hockey game, and I made it substantially worse over a year attempting to cycle and elliptical. Currently simply walking 500 feet causes discomfort. 

My OS gave me orthovisc injections, and sent me to physio to try to strengthen my VMO. There has been no improvement whatsoever. 

I'd like to attempt some type of surgical fix. Would microfracture be a reasonable first step?

                                                                                                                      Tina Triathlete

This is a request from an active athlete who wishes to remain so.  Tina is describing a  problem with the articular or joint lining cartilage. The phrase "full thickness chondral loss" refers to the cartilage on the back of her knee cap.  Although we as humans seem to tolerate arthritis in this part of the joint better than the weight bearing areas, Tina has an area where the cartilage has been worn completely through down to the underlying bone.  Although this sounds like something old people - watch it there, Post - have, it's really quite common in the athlete.

When the joint lining cartilage begins to break down, arthritis if you will, the owner has a problem.  It doesn't happen overnight and very frequently the owner of the knee is hard pressed to remember a specific accident or incident that lead to the current complaints.  Initially of course, conservative (read non-operative) options are tried including activity modification, NSAIDs, injections of various substances, maybe even physical therapy or bracing depending on the situation.  If these prove unsuccessful, the talk may turn to arthroscopy of the knee, usually performed in the outpatient setting under either general or regional (not local) anesthesia.  Two or three, one quarter inch incisions, so small that suture closure is rarely necessary, is all it takes.

One of the tools available 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 microfracture 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 may 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.







Surgeons have tried a number of different options over the years to try and make this a life long repair. OATS, Osteochondral Allograft Transfer is one attempt.  It allows the operating surgeon to transplant normal articular cartilage from one part of the knee to another.  But, the indications are pretty narrow.



In this months Journal of Arthroscopy and Related Research a study by Steadman, et. al. discusses the use of stem cells (See my blog from 10/25/2011) to augment microfracture.  They note that "Arthroscopic and gross evaluation confirmed a significant increase in repair tissue firmness and a trend for better overall repair tissue quality..."  Although this particular study was done in horses, I suspect that further studies using a human model are right around the corner. Physicians have been harvesting stem cells (frequently from an area of the low back) and re injecting them for a variety of conditions over the years.  One such treatment is called Regenexx ( see www.regenexx.comm) where, for a host of conditions, the non-surgical use of stem cells seems promising in the short term.

A fascinating recent development in cartilage repair is called BioCartilage, "designed to provide a reproducible, simple and inexpensive method to augment traditional microfracture procedures.  It is developed from allograft cartilage that has been dehydrated and micronized. BioCartilage contains the extracellular matrix that is native to articular cartilage" made by the Arthrex Corporation.

                                                                                                                                                                          Biocartilage 0 large



This is a relatively new product but the hope is that it produces a more permanent match to one's own articular cartilage.  If it develops a successful track record over the long haul, it could be a real boon to the athletic community.

"Hold on to 16 as long as you can, changes come around real soon make us women and men*."
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Calories
(noun)

Tiny little creatures that live in your closet and sew your clothes a little bit tighter every night.


Images 2, 3 Arthrex Corp
* John Mellencamp

Friday, June 27, 2014

A New Approach to Vitamins: None a Day

Why You Can Leave the Vitamins and Other Potions at the Store

Breakfast at Lava Java on Alii Drive is hard to beat.
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The title of this piece comes from an article by Valerie Ross in Men's Journal magazine.  I feel it goes hand in hand with the blog post I put up a couple weeks ago, Why I Say You Shouldn't Bother With Supplements.  We seem to be at a cross roads in athletic performance asking for data or evidence to support the things we do, or those we choose not to.  It seems like very week some tri "expert" is touting the supposed benefits of yet another mystery drug recently uncovered from the ancient Incas or the bark off some Chinese tree.  With respect to what goes into our mouths, we owe much of this current self examination to two doubters if you will, Paul Offit, MD, author of Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine and Matt Fitzgerald who penned Diet Cults.  

Both of these investigators challenged what we think we know about what we put into our bodies and the expected results.  We triathletes are a gullible group for certain.  This author included!  We tend to jump on whatever cult or band wagon comes along, if at least on the surface, sounds like it might help us.   Take the rage in California juice cleanses as one example, said to purge us of contaminants like a belly full of little Roto Rooters.  (Don't you just hate it when those old contaminants hang around?  Like those creatures in the movie Ghostbusters I imagine.)  But then along comes Sports Nutritionist Kim Mueller who writes "There are no benefits to cleanses consisting of only juice or other liquid concoctions" on Ironman.com.  Oh well, so much for my little Roto Rooters.

According to the Huffington Post, upwards of 40% of us take multivitamins. Because we always have.  Or because it seems like a good idea.  Mom wouldn't steer us wrong, would she?   Interestingly, HP notes that most of the folks who do are educated, make a reasonable income, eat well and "already get the nutrients they need from their diets."  In fact, Regan Bailey, a nutritional epidemiologist with the National Institutes of Health, the big guys, points out, "It's almost like the people who are taking them aren't the people who need them."  Fitness writer Matt Fitzgerald, also not a supporter of supplements or super foods, encourages us to become what he labels as agnostic healthy eaters patterned after the world's healthiest group of people, elite endurance athletes.  Fitzgerald writes that "Diet cults are unnecessary to the maximum attainment of health."  In other words there are no forbidden foods, although some are food choices are encouraged more than others.  Rather than blindly follow the recommendations of the past, like massive doses of vitamin C which for many years was believed to be the preferred way to ward off common colds, etc. simply ask for evidence of effectiveness before you put something new in your mouth.  And not just some anecdotal evidence that athlete ABC has used this substance and dropped his or her PR by 10%. 

 Nobel Laureate Linus Pauling convinced the world that 1000 mg or more of vitamin C taken daily would rid us of the common cold and may even be effective against cancer.  However, according to Stephen Barrett, M.D. "at least 16 well designed double blind studies have shown that supplementation with vitamin C does not prevent colds and at best may slightly reduce the symptoms of a cold."

The bottom line for now seems to be that the government still supports the use of folic acid if you're thinking of getting pregnant and iron if you are assuming you can't get enough of this from your diet while pregnant.  The jury is out on calcium, helpful in some but not all.  And I'll bet you'd find wide support for a little extra vitamin D which we're supposed to get from the sun but don't.  Especially in winter.  Lastly, a whole passel of us are magnesium deficient but I'll let you talk that one over with your health care provider.



So for now leave those multivits on the shelf, become a Fitzgerald agnostic healthy eater and give yourself the best shot at great performance.  And when some tri expert tells you how triple your libido by consuming some special root from Nigeria or Asia, as Cuba Gooding, Jr. says in Jerry Maguire"Show Me The Money."  Show me the evidence based recommendations.

Tuesday, June 24, 2014

Triathlon Coach, The Guardrail of Training



"A good coach produces beneficial reactions to training, creates positive race results, and transforms the athletes he or she brings into the program into better runners (and one hopes, better human beings)."       

                                                             Jack Daniels, Phd.  "World's Best Running CoachRunner's World

After last year's race in Hawaii, I saw two athlete surveys asking the competitors about whether or not they have a coach.  The first reported just over 50% saying yes and the second over 60% reporting that they were coached.  Think about that for a second.  In your group of friends, what percent use the services of a coach?  A lot less than 50% I'll bet.  But then how many in your group of friends were told "You are an Ironman" by Mike Reilly, voice of Ironman, on famed Alii Drive last October?


Bike inspection. Will it safely go 112 miles. The answer is not always yes.

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Otto Lilienthal, predecessor to the Wright Brothers, stalled his glider August 9, 1896 plunging 50+ feet and crashing. His spine was broken and he died the next day.  His last words: "Sacrifices must be made."  While hopefully not on this scale, most triathletes would understand Lilienthal's sentiment exactly.

 Now in June/July of our race season, it's a time when all of us begin to reevaluate our seasons, what's going well and what's not.  Harry Chapin, in a song called Mr. Tanner, about a baritone from the midwest, penned the line, "he did not know how well he sang, he only heard the flaws." Some of us train that way.  We're really hard on ourselves.  It can be fairly destructive.

In essence, at this time of year we look at where we are and where we want to be and ask ourselves, "Now what?"

OK, here's my disclaimer.  I've worked with two triathlon training companies in a no pay arrangement helping their injured athletes for several years.  Oh, and helping their athletes not injured stay that way.  When I was still racing iron distance I had a coach.  Joe Friel.

In Coach Daniels books you find the following statement: "There are four key ingredients for success in distance running {or triathlon}" - or for many other pursuits in life, for that matter.  They are, in order;

1) inherent ability
2) motivation
3) opportunity
4) direction.

Note the importance of ability.  Those new aero bars may contribute to your success but without the right genes, the success you seek may elude you.  Think about it this way.  Golfing legend Lee Trevino is quoted as having once said, "It's not the arrow, it's the Indian." Ability is at the top of the list for a reason.  The direction part is where we find ourselves today and whether or not outside advice will help us achieve our goals.

So, as you begin to formulate the remainder of your season, think about whether a coach fits into your lifestyle and checkbook.  Heck, for what some will put out for a new set of aero wheels, they could get a full year, or more, of coaching.

Abraham Lincoln advised, "He who represents himself has a fool for a client."  While I certainly don't think it's a direct carry over to our sport, if you want to make it to the top, and what you've tried to date hasn't gotten you to where your inherent ability can take you, think about getting a coach.  You might like to try it for a year and see if the benefit is worth the price. It's certainly not for everyone but it might be for you.  50 -60 percent of those in Hawaii would agree.

Monday, June 16, 2014

Kona Swimmers, A Floating Coffee Bar, And it's Free!


Mohala i ka wai ka maka o ka pua
    Unfolded by the water are the faces of the flowers

 "Hope is our willpower and waypower in our lives.  It is our beacon to achieving our goals and fulfilling our dreams.  No matter what our journey holds - hope gives us the strength to dream, to carry on and to evolve."  



                                     Official Program, IRONMAN World Championship, 2013




After a hot cup of Joe, swimmers head back to the Kailua-Kona pier.

Kona Bay, Ironman Week 2013 - One athlete surveys the horizon, still obscure with the just rising sun. “What the heck is that?” he wonders as he spies a vessel seemingly under sail, a few hundred meters off the tip of the Kailua pier.  It seems to be handing something to those swimming by.

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 make the Ironman World Champioship truly 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 you're floating in the Pacific Ocean.  Is that cool or what?  You gaze around at the other swimmers doing likewise, and all at once a big laugh breaks out at the absurdity of this moment.  Like the t-shirt says, life is good. I couldn't agree more.

A number of industry booths have popped up on the pier from goggles to supplements to energy drinks 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.

                                                                                                              

Tuesday, June 10, 2014

Why I Say You Shouldn't Bother With Supplements

One Last Thought On Vibrams

One industry expert told me that every time he helps a customer with Vibrams, he asks if they got the free shirt with the shoes.  To which the customer usually gives a puzzled look and responds, "no..."  The rep then responds, "it's the one that reads 'SUCKER' right across the chest."
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Supplements, Spend Your Money on Something Else


I've never been a fan of supplements.  I mentioned in a previous blog a story about my roommate in Kona one year who mixed up a dozen or so pills, liquids, gels and powders in a blender, ground them up into this grey slime reminiscent of Dan Ackroyd's portrayal of the pitch man pushing a Super Bass-o matic 76 - it's pretty funny -  http://bit.ly/1oLowQf .  And down the hatch.  When asked which of these many supplements was responsible for his Kona qualification, he shook his head and said, "Who knows, but they can't hurt me other than making me poor, right?"  Well, probably not right.

Every year the sports world is once again surprised when one substance or another, take deer antler spray for instance, which is quietly sold to a subset of unsuspecting athletes who swallow the promises of those hawking the supplement as that which will surely give them greatness. Shortly thereafter, the product is exposed to either not do as promised.  Or worse, as a result of shoddy manufacturing technique and testing, the athlete tests positive for a banned substance which, sadly was an impurity (at best) in this great "aid" to performance, and the unsuspecting athlete is banned from sport.

The New York Times published an opinion piece in December that I'll reproduce in it's entirety below to give you kind of a middle of the road approach on the logic of why simply accepting anecdotal evidence from generic pro triathlete ABC without evidence based research or knowledge of manufacturing standards might not be your best course of action toward improving your triathlon performance.  


_____________________________________________________
By PAUL A. OFFIT and SARAH ERUSH
PHILADELPHIA — PARENTS whose children are admitted to our hospital occasionally bring along something extra to help with their care: dietary supplements, like St. John’s wort to ameliorate mild depression or probiotics for better health.

Here’s the problem: The Joint Commission, which is responsible for hospital accreditation in the United States, requires that dietary supplements be treated like drugs. It makes sense: Vitamins, amino acids, herbs, minerals and other botanicals have pharmacological effects. So they are drugs.

But the Food and Drug Administration doesn’t regulate dietary supplements as drugs — they aren’t tested for safety and efficacy before they’re sold. Many aren’t made according to minimal standards of manufacturing (the F.D.A. has even found some of the facilities where supplements are made to be contaminated with rodent feces and urine). And many are mislabeled, accidentally or intentionally. They often aren’t what they say they are. For example:

In 2003, researchers tested “ayurvedic” remedies from health food stores throughout Boston. They found that 20 percent contained potentially harmful levels of lead, mercury or arsenic.

In 2008, two products were pulled off the market because they were found to contain around 200 times more selenium (an element that some believe can help prevent cancer) than their labels said. People who ingested these products developed hair loss, muscle cramps, diarrhea, joint pain, fatigue and blisters.

Last summer, vitamins and minerals made by Purity First Health Products in Farmingdale, N.Y., were found to contain two powerful anabolic steroids. Some of the women who took them developed masculinizing symptoms like lower voices and fewer menstrual periods.

Last month, researchers in Ontario found that popular herbal products like those labeled St. John’s wort and ginkgo biloba often contained completely different herbs or contaminants, some of which could be quite dangerous.

The F.D.A. estimates that approximately 50,000 adverse reactions to dietary supplements occur every year. And yet few consumers know this.

Parents of children admitted to our hospital often request that we continue treating their child with dietary supplements because they believe in them, even if that belief isn’t supported by evidence. More disturbing were the times when children were taking these supplements without our knowledge. Doctors always ask parents if their children are taking any medicines. Unfortunately, because most parents don’t consider dietary supplements to be drugs, we often never knew about their use, let alone whether they might react dangerously with the child’s other treatments.

The F.D.A. has the mandate, but not the manpower, to oversee the labeling and manufacture of these supplements. In the meantime, doctors — and consumers — are on their own.

Our hospital has acted to protect the safety of our patients. No longer will we administer dietary supplements unless the manufacturer provides a third-party written guarantee that the product is made under the F.D.A.’s “good manufacturing practice” (G.M.P.) conditions, as well as a Certificate of Analysis (C.O.A.) assuring that what is written on the label is what’s in the bottle.

The good news is that we’ve been able to find some vitamins, amino acids, minerals and a handful of other supplements that meet this standard. For example, melatonin has been shown to affect sleep cycles and has a record of safety, and we identified a product that met manufacturing and labeling standards.

The bad news is that this was a vanishingly small percentage of the total group. Around 90 percent of the companies we reached out to for verification never responded. They didn’t call us back, or their email or manufacturing addresses changed overnight. Of the remainder, many manufacturers refused to provide us with either a statement of G.M.P. or a C.O.A.; in other words, they refused to guarantee that their products were what they said they were. Others lied; they said they met G.M.P. standards, but a call to the F.D.A. revealed they had been fined for violations multiple times. Perhaps most surprising, some manufacturers willingly furnished information that their product didn’t meet standards — like one company that provided a C.O.A. showing that its product contained 47,000 International Units of beta-carotene, when the label stated 25,000.

Now, when parents in our hospital still want to use products whose quality can’t be assured, we ask them to sign a waiver stating that the supplement may be dangerous, and that most have not been studied for their effectiveness. “Use of an agent for which there are no reliable data on toxicity and drug interactions,” the waiver reads, “makes it impossible to adequately monitor the patient’s acute condition or safely administer medications.”

What can other individuals who are concerned about supplement safety do? They can look for “U.S.P. Verified” on the label — this proves the supplement has been inspected and approved under the United States Pharmacopeial Convention. Unfortunately, fewer than 1 percent of the 55,000 or so supplements on the market bear this label. The real answer is that, until the day comes when medical studies prove that these supplements have legitimate benefits, and until the F.D.A. has the political backing and resources to regulate them like drugs, individuals should simply steer clear.

For too long, too many people have believed that dietary supplements can only help and never hurt. Increasingly, it’s clear that this belief is a false one.
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Skip the supplements - http://www.nytimes.com/2013/12/15/opinion/sunday/skip-the-supplements.html?

Paul A. Offit is chief of the division of infectious diseases at the Children’s Hospital of Philadelphia, where Sarah Erush is the clinical manager in the pharmacy department


Image 1, Google Images 

Walking into the Ironman store.


  


Thursday, June 5, 2014

Kona on the Cheap, Even Just to Volunteer: Do It!

How to go to Hawaii and still be able to afford airfare home.


If you look closely you'll see each entrant's name on this banner. It's pretty cool.

I've been to Kailua-Kona, or simply Kona as most refer to it a number of times and learned that I don't need to break the bank. In other words, I haven't run the race in a number of years, but still volunteer each year, and can do it without a second mortgage on the house.  This way, even folks who know they'll never qualify can be an important part of the event as a bike catcher or transition tent volunteer.  Or both!  The Hawaiians call it "Share the Aloha" and, like Woody Allen says, "80% of life is just showing up."  So don't just assume it's out of reach.  Do the math, take a chance.

These two "hot chicks" just finished the Underpants Run, an essential in your Kona stay
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 So where do we start?  How about the biggies, transportation, lodging and food.  The instant you decide to commit, book the flights trying to use frequent flyer miles.  I did.  An example would be as follows: I just looked at United Airlines, Dulles to Kona, and would be able to book a round trip 10/8 - 10/14 with 57,000 frequent flyer miles and $10.  But it might not be available tomorrow.  Or even this afternoon.  The lesson here is if you see flights that work, even if they're a day, maybe two off of your plans, book 'em right then.  They change all the time.  It'll work out.  Remember that the penalties for overweight luggage can be significant.  Many of us hit the Ironman store to bring IM gifts for the folks back home.  I suggest you pack a canvas collapsible bag in your suitcase so if you're reaching the weight limit, you only pay a 2nd bag fee instead of the penalty. 

The other big part of transportation is a rent-a-car.  I just checked Budget, and, unusually, they offer one car for $214.09 for my theoretical week's stay but all the rest are over $400. However, most of the time you don't need a car here.  Walk, hitch, take the Keauhou Trolley that goes up and down Alii Drive all day for $2.  Just get a copy of the schedule.  Ride/or borrow a bike.

As for a place to stay, that's usually not very hard.  I book a condo every year, about a mile from Lava Java - "where the elite meet to eat" - as they used to say.  And, at the moment, I only have one roommate, there rest will come from sources like this, Slowtwitch, VRBO, Twitter, etc. where folks are looking to split expenses.  I think we were $425 each or so for the 9 day week last year.  For some hotels that would only get you two nights.

There are a host of options for food.  If you stay in a condo with a refrigerator, you're set.  A visit to Sack N Save grocery store on Palani Road will help.  As you go in, stop at the service desk and ask for a Makai card.  It will save you plenty.  Pick up what you need for breakfast, snacks, beer, soda, whatever so that you're not paying restaurant or convenience store prices later in the week.  That said, you have to plan on a couple of meals at Splasher's located right at the IM start/finish for unparalleled people watching, or Lava Java where the company is good and the food better.  Thursday night before the race is the E Komo Mai (Welcome) Banquet.  It's fun but not inexpensive. A number of people seems to have extra tickets that they're not using and if you keep an ear out you might snag one.

Bring everything you might need with you.  Snacks, gels, sunscreen, goggles, tubes, etc. except CO2 cartridges of course.  Vern Sekafetz at Bike Works is a tremendous help with the rest.

In short, for many of you, if you think through the numbers and the benefit you get being at the finish line at midnight of the World Championship screaming to help the final finisher across the line, it's time you'll never forget.  See you on Alii Drive.


Monday, June 2, 2014

Swimming Tips for Your Travel/My Stupid Mistakes in a Foreign Pool


There are no McDonald's in Iceland.  What do they know that we don't?
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"Next time you're in your car, strip down to your underwear and jump out the door.  That's what it's like to crash in a professional bike race."
                                                   Jonathan Vaughters



Leif Ericsson, Reykjavic, Iceland



Did you know that the first white child born in North America was Icelandic?  Neither did I.  His name was Snorri Thorfinnisson  I also didn't know that you have to take your shoes off before entering the locker room to swim in Iceland.  Just the first in a series of faux pas that did not endear me to the Icelandic people.

We all must travel from time to time, and although you can run just about anywhere, planning ahead of time will make keeping up with your home swim routine all that much easier.  Pre internet days the American Lap Swimmers Assn put out a text with 100's of pools nationwide, a task now taken on by USMS.  I still have mine.  All you need these days is the zip code of your destination and a visit to USMS.org.  Hit the Local Programs tab at the top followed by Places to Swim and you're there.  If you're really lucky your destination pool will also have a masters swim program, similarly located at the Local Programs tab.  Having learned the hard way (by driving an hour plus, putting on my suit, grabbing my swim bag and heading out to the pool deck only to find the pool bone dry for maintenance one time) I'd recommend that you call ahead to verify the info you obtained on line. You might also ask about pool fees, guest policies, or any little quirks of the area like only one open building door for early bird swim or the local Panera for after swim breakfast.  Lastly, since the whole process may be a little foreign in a new town, arriving early is always in good taste.  If you plan to do some laps with the local masters group, getting there well ahead of time will allow you to introduce yourself to the coach, get an appropriate lane assignment and start off your workout with new friends on a positive note.
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OK, back to Iceland.  So after walking into the locker room with my shoes on, getting the evil eye from another patron and directions back out of the locker room to the shoe racks around the corner, changing into my swim gear was uneventful. Until I went to shower before pool entry....in my suit.  They don't do it that way there.  So my second shower, sans suit made me squeaky clean.  There's an over abundance of geothermal energy in Iceland so this particular complex had both an indoor and outdoor 50 X 25 pool.  Even though the air temp was in the low 40's, both were being used.  I chose the indoor pool, since it's maintained at a lower temp. The pool was divided in two by a central movable bulkhead much like the one at our local university, kids lessons taking place on one side, the other for lap swimming.  But now I'm spooked. Do they swim parallel or perpendicular to the 50 M lanes.  There were no lane lines or backstroke flags to help make this decision so I swam my first 400 or so perpendicular to the lines lines on the pool's bottom, wondering why my normal stroke count of 19 was way off, until, the dip that I am, it came to me that I'm in a foreign country which uses the metric system (duh!) and it's 50 X 25 meters.  Eventually a youngster came out, jumped in, and began swimming - perpendicular to me!  What the?

So, realizing my error, that I'd made the wrong choice of directions, I swam the next 3-400...meters... his way.  He got out.  And only a little later, a second child jumped in the pool. He started swimming perpendicular to me, the direction I had started originally!  I swear, this is one confusing place.  They must think I have the IQ of a lamp shade.

After swimming I realized I had lost the electronic locker key and I needed to again speak with Mr. Locker Room Enforcement Police Guy who made me take two showers...the only one in the building who didn't speak English.  This won't go well.  Somehow, through sign language, I made my point.  He produced the missing item and was not smiling.  Wonder why.  So I walked back to my locker, got my shampoo and stuff, only to be again accosted by Locker Room Guy for not toweling off to go into that area.  He sternly pointed out the sign to me...in Icelandic only naturally, which I don't understand...which I suppose made that instruction obvious.  To Icelanders maybe.
  I finished up and exited the building pronto.  If I ever go back, I'll not make those mistakes again.  Maybe I'll rent a bike.