Monday, September 24, 2012

Marathon Medical Tips #2.3

Injury Prevention: 
Doug Ichikawa, D.P.M
Teaching Associate,  Orthopaedics and Sports Medicine 

"Don't eat and then go swimming."  "Wear a jacket and warm-up if it's cold outside."  "Stretch before you play."  We have all heard these and other common words of advice from parents, friends, and coaches on how to avoid injuries during athletics.  So what do you need to know before running a marathon that will keep you healthy, prevent injuries, and allow you to accomplish your goals?
This simplistic statement may summarize the best strategy: "Prevention is the best treatment."  While easier said then done, appropriate training and race-day planning are the keys to preventing injuries during a marathon.  Many runners decide to pursue a marathon but allow only a short timeline to prepare.  In fact, the vast majority of overuse running injuries are directly related to training errors, or running too much too soon.

Training for any athletic endeavor should be gradual.  Muscles, tendons, bones, and the cardiovascular system all need time to adapt to the stresses of conditioning.  Runners should begin by calculating their total weekly mileage.  Training often consists of lower mileage and speed runs during the week, and a single longer run on the weekend.  Runners should be careful not to increase their total weekly mileage by more than 10% per week.  If you are new to running, successful training for a marathon may take 6 to 12 months, or even longer.  Abrupt increases in running distance, intensity, or frequency may cause common overuse injuries such as shin pain, patellar tendonitis, iliotibial band syndrome, plantar fasciitis, or even stress fractures.  Most of these injuries can be avoided by proper training and allowing the body to gradually adjust to the demands of higher levels of conditioning.

Stretching and a proper warm-up are also important.  Similar to a slow progression in running distance, the body needs adequate time to warm-up before heavy training or competition.  A light short distance jog and gentle stretching will assist the body and muscles to properly prepare for more intense exercise.  The exact warm-up routine will vary from person to person, but each runner should be comfortable with their routine - including stretching, warm-up, meals, shoes and clothing - prior to the marathon.

Unfortunately, not all injuries can be avoided.  From blisters to leg cramps, you must be prepared to modify your running if unforeseen problems arise.  Runners should not "push through" significantly painful symptoms.  If you develop unexpected limitations, slow your pace, walk, rest, or stretch before attempting to continue.  If you develop major symptoms such as chest pain, difficulty breathing, lightheadedness, or confusion, stop immediately and ask for help.

Remember, train appropriately, plan well, listen to your body, and, most of all, think safety first!

Marathon Medical Tips #2.2

 Runner's Knee
Mark Harrast, M.D.
Director, Sports and Spine Fellowship
Medical Director, Seattle Marathon
Clinical Associate Professor of Rehabilitation Medicine and Orthopedics and Sports Medicine

Erin Maslowski, M.D.
Sr. Fellow, Rehab Medicine 

Knee pain can strike any runner, from novice to seasoned veteran. One cause of knee pain is so common in running athletes, it has been called "Runner's Knee." The medical term for this problem is Patellofemoral Syndrome, so called since it is caused by abnormal forces between the patella (knee cap) and femur (thigh bone). Normally, the knee cap rests in a groove at the tip of the femur. Abnormal tracking of the knee cap in this groove causes soreness. Fortunately, this condition usually responds to appropriate treatments.

Runner's Knee commonly causes pain behind the knee cap. This is made worse with positions or activities that increase the pressure between the knee cap and the femur. Often, pain is worse with sitting for prolonged periods and climbing or descending stairs. Swelling may occur and the knee may feel unstable. Runners may notice pain during their run, a short while after running, or even the day after a workout.

The cause of Runner's Knee is not fully understood. Traditionally, weakness of the vastus medialis (the inner most quadriceps muscle) was thought to contribute to abnormal tracking of the knee cap and result in pain. More recently, weakness of the gluteus medius and other hip muscles has been recognized as a contributing factor. The hip muscles support the body and control the femur during running. When these muscles are weak, the thigh may drift inward and contribute to abnormal tracking of the knee cap. While runners are usually strong in their hip flexors due to their training, they are commonly weak in hip abductor (gluteus medius) strength. Whatever the cause, Runner's Knee is easily treated. Initially, one can ice the affected knee approximately 20 minutes, several times per day. Judicious use of over the counter medications such as acetaminophen or anti-inflammatories can be helpful. Often, rest from running will improve symptoms as well. If these first line approaches do not provide adequate relief, see your regular
doctor or sports medicine specialist for other treatment options. These might include a specialized brace or taping to stabilize and support the knee cap. Measures to optimize biomechanics can help provide lasting relief from Runner's Knee. These include use of orthotics, when appropriate, and a physical therapy program to strengthen those weak muscles that play a key role in supporting the knee.

Marathon Medical Tips #2.1

Anti-Inflammatory Medications

Connie Davis, M.D.
Preofessor of Medicine
Director, Kidney Care Line
Co-Director, Kidney and Pancreas Transplant

It hurts now and boy it is going to hurt in another few hours! How about taking a few more ibuprofen, or better yet maybe my doctor will give me some more long acting anti-inflammatory medications to prevent my suffering after the big race.  Be careful what you ask for, it may cause more harm than good.

Non-steroidal medications (NSAI's - such as Advil/ibuprofen, Aleve/naproxen, Indocin/indomethicin) that are so effective in preventing inflammation, muscle and joint pain after extreme physical exertion also cause problems in kidneys and the gastrointestinal tract.  So before you reach for that medicine bottle, think about why you are taking them and what you need to do to reduce your risk.  The dangers of NSAI's are stomach bleeding, general increased bleeding and decreased kidney function. Kidney function is lower after a race in those who use NSAI compared to those who do not. Also of concern, especially for race day, is the association of NSAI's with low blood sodium (hyponatremia).  This side effect is pronounced if you drink too much water during the race and is seen in up to 13% of marathon runners. The older you are the higher the risk for all side effects. Smaller people also seem to be at increased risk for hyponatremia. Finally, although heart attacks have definitely been associated with the use of more selective NSAI's (such as celecoxib/Celebrex and rofecoxib/Vioxx) this risk may also occur with nonselective NSAI's such as diclofenac (Voltaren).  It is possible this is true for other non-selective NSAI's but to date has not been proven for ibuprofen and naproxen.

Kidney damage is caused by NSAI's.  First NSAI's may cause an allergic reaction in the kidney's filtering and/or processing unit.  Either of these events may cause permanent kidney failure.  The only treatment is to stop NSAI use.  The way you would know such a reaction had developed is through the onset of swelling in feet and ankles and/or blood and urine tests. Rarely you might develop a rash and fever. Second, NSAI's may cause kidney dysfunction by decreasing kidney blood flow.  This happens when people are dehydrated, during extreme exercise or have kidney, liver or heart problems.  One in five people taking several days of a NSAI will have a decrease in their kidney function. Third, people with high blood pressure who take NSAI's may have major problems with blood pressure control even if they are treated with blood pressure medications. And fourth, hyponatremia or low blood sodium is increased in runners using NSAI's.  It is particularly common if someone drinks too much water because NSAI's decrease your kidney's ability to get rid of excess water.  It does this by increasing the kidney's ability to reabsorb water. Low serum sodium levels may lead to headache, nausea, vomiting, confusion, seizures, weakness, problems breathing and collapse.   With long-term use of NSAI's the risk of permanent kidney failure that requires hemodialysis treatment may be up to 0.8%.  This is over eight times the risk of the general population.

The best way to protect yourself is to not use NSAI but if pain is so severe then the best thing to do is take NSAI with food, a medicine that decreases stomach acid production (heart burn medication such as pantoprazole (Protonix) omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid) or misoprostol (Cytotec)), hydrate only as advised by the race hydration sheet and use for a limited time, up to two days. Repeated doses and prolonged use of NSAI should be avoided especially if using the long acting products.

Alternatively you may take acetaminophen (Tylenol) but no more than 4gm per day and preferably not every day and not in conjunction with alcohol for fear of liver injury.   If you have high blood pressure, take blood thinners or have a bleeding disorder, liver problems or kidney disease NSAI's should not be used. Concomitant use with diuretics (water pills) is not advised. Lastly, realize that if you develop a stress fracture or a complete break, healing may be delayed if you use NSAI.  Running through the pain with the aid of NSAI is something that you should discuss with your doctor as you may be hiding a significant injury.