Taking Things in Stride

Stress Fractures

2011-05-15T05:13:00.000-07:00

The young, intelligent and fast Camille Herron wrote this interesting piece on her blogsite about stress fractures. It is a thorough look at the causes of this malady and what she had to do to overcome her recurrent stress fractures.

Do Foot orthotic Devices Work?

2011-01-19T17:24:00.000-08:00

This post is in response to Jon Waldron , the author of the excellent Newton North blogsite. He asked me to comment on the January 17 article in the New York Times, so here are my thoughts.

In summary, the article doubts the effectiveness of foot orthotic devices (FODs) with the author backing up her points with quotes from the co-director of a human performance lab in Canada. FODs are usually discussed in terms of how they modify pronation and supination. These terms are one of the most simplified and abused terminologies in journalism today. With this article, add sensationalism to that list. It gets "eyeballs" to the Times website and sparks commentary but is not much good for more than that. This is because those eyeballs would glaze over if any attempt at what we really know about these foot motions were ever presented. These said motions describe tri-plane motions around a single joint and not a whole foot. For example pronation at the subtalar joints generally causes most of the foot to be a loose bag of bones while supination makes the bones to be a "rigid lever." However, at the neighboring mid-tarsal joints, pronation locks the foot rigid while supination causes the loose bag of bones" situation. That is the effect of only 2 of the 33 joints on basic foot motion. Dare we add in the others? How about force changes from the 100 or so muscles and tendons or the peak forces on the 26 foot bones. Don't forget the angular velocities transmitted from the rest of the body. We live in a world that is not black and white but somewhere along the spectrum of gray. The answer far less pessimistic than that of Gina Kolata article in the New York Times and far less optimistic than a foot orthotic device (FODs) chain that claims 98 percent sucess with its clients. IMHO, I see this as that classic academic/theoretical voice clashing with the clinical/practical stirred by the journalistic tempest in a teapot. For those of you that see a tipping point towards academia (Dr Benno Nigg) and away from the fee for service clinicians, think again. The article does not disclose that the good doctor has a financial interest with MBT shoes (Masai Barefoot Technology). These shoes are supposed to create instability and inefficiency in the short term to strengthen feet for the long term. Their thinking and selling point for their shoe line is that if you strengthen the muscles involved, you don't have to correct for any deformity. Hence, you can now better understand his obtuse comment that FODs are only a short term solution.

Of course foot orthotics devices work when given to someone who actually needs them and the results are long term. There is too much evidence based medicine to refute this. The kicker is that less than 10% of the injured runners that seek my care show clinical evidence that they would even benefit from FOD therapy. So we are talking about a small percentage of the general running population. Let me digress. Every runner that enters my office is screened for deviations at the subtalar and midtarsal joints as well as a host of other clinical and historical information. Dr Richard Schuster measured over 10,000 runners and found statistical correlations between these numbers and certain injuries. For example, he found a high correlation between abnormally high forefoot varus and patello-femoral syndrome. Then I take into account any structural and material "defects" in the foot or even specific things in the past medical history to honestly and profesionally decide whether a custom FOD is a viable treatment for this person or whether other avenues need to be persued. There are people "prescribed" FODs by unscupulous practioners and clinics that don't have much clinical evidence that they actually need them. People who get devices they do not need won't be helped and are sometimes hurt by such teatment. This is further fed by patients that think they need them, or maybe just want them. Then there is the group of people that show some evidence of needing correction but are given the wrong prescription. One area sports clinic had their FODs made by a 7 dollar per hour nurse's aide with no formal training. The outcome of wrong presciptions lead to truly random outcomes. one of the more common errors I see is how the foot impression is captured. Clouding the issue is that how a FOD fits into a shoe can affect how well or how badly the foot functions in that shoe.

For the record, I do think that some form of strengthening of specific foot stuctures within a reasonable margin of error can be injury reducing. However, I doubt that these new "toning shoes" are that answer. In that small percentage of people that have foot deformities that cause stress and forces that exceed safety limits of what that body part can handle, something must be done to reduce it. In those special cases, custom made proper prescription FODs perform quite well.

Take two and you WILL be calling me in the morning

2011-01-16T06:48:00.000-08:00

Use aspirin analogs (or other NSAIDs like motrin and Aleve) have been touted as half of the gold standard of the first aid of sports injuries. However such drugs might not be the gold standard it is cracked up to be.

Aspirin or acetylsalicylic acidwas dicovered in 1827 when a crude product was extracted from willow bark. In 1844, another related chemical was extracted from the oil of Gaultheria (oil of wintergreen). This related compound is still used today an an ingredient of liniments, such as Ben-Gay. Aspirin in the form we know today was introduced in 1899. This inexpensive "wonder drug became a staple of medicine chests worldwide.

An oral dose is absorbed rapidly through the stomach and small intestines and is bound to blood proteins. Apreciable amounts can be detected in the blood within 30 minutes with peak amounts in about 2 hours. It is removed from our bodies by the kidneys and, to a lesser extent, the liver.

In even low doses, asprin analogs makes platelets (a component of blood) less sticky. This is good for ailments where stickiness causes clots like heart attacks and strokes. However it is negative when talking about a fresh musculo-skeletal injury. Excessive bleeding into the injury site causes hematoma formation which can delay healing or even cause incomplete healing.

At higher doses of these drugs you mask mild to moderate pain. It takes even higher doses to reduce imflammation. However, even if you dose yourself correctly to adress the imflammation, this might not be a good thing. Researchers at the Cleveland Clinic recently published a study that adds to growing evidence that swelling actually plays a key role in healing soft-tissue injuries. The result is a classic tradeoff between short-term and long-term benefits: reducing swelling with ice or drugs may ease your pain now, but slow down your ultimate return to full strength.

When you sustain an injury, your body’s first response is to send cells called macrophages to clear away the damaged cells by literally digesting them. This initiates a complex process of repair and regeneration that triggers swelling, in part because macrophage-induced damage pokes holes in the muscle membrane, allowing fluid to rush in.

What the Cleveland study showed is that these macrophages, in addition to causing swelling, are also the primary source of “insulin-like growth factor-1,” which crucial to the growth hormone process which rebuilds our body tissues. If you take away the swelling, you also lose the growth factor.

This finding offers an explanation for clinical evidence about the double-edged effects of otherr anti-inflammatory drugs that has been mounting for several years. A review published last month in The Lancet found that injections of cortisone, a powerful anti-inflammatory steroid, brought initial relief for tendon injuries such as tennis elbow, but produced significantly worse outcomes six and 12 months later compared with patients who did nothing or performed physiotherapy exercises.

There is a use for anti-imflamatory drugs in certain situations. However, there are many more cases of abuse where the short term clouds the long term. So take two and you WILL be calling me in the morning.

Preventing Slip-ups

2011-01-01T05:20:00.000-08:00

The first snowfall of the season usually makes for a scenic and serene run. However, the poetic karma quickly loses its luster as the winter weather wears on. The treadmill is okay for for short stretches of time. But, I don't call it the dreadmill for nothing!

Slips on ice are a product of shearing forces and lack of traction. Shear shifts a full 180 degrees during a single foot strike while running in a straight line. This is why sometimes you feet go first and other times you fall flat on your face. Even greater shear is put on the foot when you suddenly turn in either direction. So it is always important to have a heightened sense of traction awareness when making a turn.

One can improve traction in winter conditions with this little trick.

http://www.youtube.com/watch?v=us82woC7RMM

Hot tip

2010-10-28T16:15:00.000-07:00

The late Larry Olsen was a big proponent of over-dressing for workouts whenever he could. He may have had other proprietary secrets that he took to the grave with him. However I took the overdressing tip from him in 1995 when I trained for the World Masters Cross-country Championships. The first t-shirt/shorts day of the spring, I resisted the urge to enjoy that textile freedom. Instead, I wore my Jacket and tights. I continued to dress for 10-15 degrees cooler than the day actually was until the big race (July). I race very well that year, especially in the heat.

Now, University of Oregon Human Performance Lab lends scientific support to his idea.

http://comm.uoregon.edu/archive/news-release/2010/10/heat-acclimation-benefits-athletic-performance-hot-and-cool-conditions

Stretching: The Truth

2010-10-10T07:21:00.000-07:00

In recent years, stretching exercises have become a controversial issue, with most of the press, and nearly all of the sound bites, being against it. You would think that stretching is bad for you, rather than being a valuable tool kit in the fight against injuries and for the improvement of performance. The problem is that the buzz about stretching, as if it is one thing that everyone should do as a routine all the time, rather than being a time specific and person specific thing.

Stretching exercises are usually lumped together as one thing. This is like a tool kit of just one type of hammers. It's great if you need to pound a nail. If you need to advance a screw, you are well... just plain screwed. It is more helpful to categorize the types of stretching, in order to understand that stretching is a broad category.

A functional categorization would be:

Active/Dynamic the opposite muscle groups fire to stretch the muscle but in an controlled understated slower way than the intended activity. Think of a ballerina warming up at the bar or a lunge exaggerated walk. When there is a bob or bounce at the end of the motion.
Ballistic this is a term in the literature for when there is too great of a bob or bounce at the end of the active/dynamic stretch. The truth is that there is certain situations where this type has value and the key is in the acceleration and velocity of the bob. This motion can be gentle as a Tai Chi motion or as violent as the field goal kicker kicking footballs repeatedly into a net.
Passive the body part is manoeuvred into position and held there for a set length of time. However, passive stretching requires a partner, machine, object, wall, or floor to generate external force.
Static involves stretching a body part to a set amount without pain and holding the stretch for a set period of time. Think of a "wall push up" for stretching the calf.
Proprioceptive Neuromuscular Facilitation PNM is a combination of passive stretching while simultaneously doing an isometric strengthening exercise.
Yoga (means “union” in Sanskrit) and it is truly a union in that it combines active and static with proprioception overload of the central nervous system.
Running itself has a flexibility benefit. Can you not call what happens in warm up before a hard workout a stretching exercise? Do you not feel looser in the days after certain types of workouts?

If you did exactly the same workout every day, you would quickly go stale. Staleness is the shadowy gateway to destination injury. The stretching exercises you do should be a constant work in progress that addresses the present needs of your body. Once the people with traditional media acess properly design their studies, they too will find the benefit in stretching a muscle rather than stretching the truth.

Going Bananas Over Shoes

2010-06-13T12:50:00.000-07:00

I recently did a study for a shoe company where I was supposed to tell the anti-pronation shoes from the neutral shoes among four different shrouded shoes. It should have been a cinch for a biomechanics expert like me, right? I got all four shoes wrong...at least according to the company and their classifications of the pairs of shoes. A dart throwing chimpanzee would have scored better. Then again maybe I got them all correct and they need to monkey around to reclassify the shoes.

According to the company the stability shoes (their term for any shoe containing an "anti pronation device") were as such because of a medial post (their term for a heel midsole with harder rubber on the medial side of the shoe than the lateral). The problem is that fortunately such a "device" won't really work and limit pronation. I say fortunately because my clinical observations say less than one in ten people need heel contact pronation limited. It does not work because 99.9% of runners have contact with the ground on the lateral side of their foot. The center of gravity stays lateral till well after mid stance on most people. Then it shifts more medial to anywhere between the big toe and the 3rd toe at toe-off. The point is that the medial block is just 'along for the ride" and does not come into play. If such a gimick worked, there would be a lot of very hurt runners out there because supination is far more injurious than pronation.

Still follow me? If you do, you are doing better than the R & D person at the shoe company whose eyes glazed over when I mentioned this. So all shoes are really neutral shoes, right? Not quite. Many of the neutral shoes have extra cushioning because convention "wisdom" in the industry dictates this. Shock absorption and anti-pronation are the marketing talking points. Extra cushioning also hides a multitude of rearfoot to forefoot functional transition shortcomings. You could say it helps smooth out the ride. It also makes body parts zig when they should be zagging. The brain compensates by firing certain muscle groups eccentrically to dampen the motion and right the errant body part. In essence, it cosmetically glosses over the short term while putting extra strain on the said body parts long term. So midsoles that are too soft are like putting lipstick on your "piggies."

So, anti-pronation shoes do not really limit pronation and neutral shoes randomly affect foot function depending upon the durometer of the midsole rubber under your personal center of gravity axis lines. Running shoe classification is not a science. It is an art. It is an art to limit the random avenues in the search your proper running shoe. What this means is be careful to trust less the company classification of the shoe and trust more what past experience tells you. If a model works out for you after a few weeks of running, go out and buy a couple more pairs of that shoe before they discontinue the model. Finally, make one of those pair into your "Sherlock shoes.

If the shoe fits...

2010-05-16T08:03:00.001-07:00

The funny thing is that if shoes met the individual needs of the runner in a better fashion, this whole shod versus unshod discussion would become a moot point. However, that is a whole other rant for another day.

Another day has finally arrived. So let me attempt to tackle a very complex issue in the most distilled form of an explantion.

My first training shoes I ever owned for running were purchased in my second year of running for 2 bucks (1969). For the first year, I used my regular sneakers. Those running shoes had a canvas upper, narrow heel, flimsy arch, and no cushioning. Such characteristics are the complete antithesis to running shoes today. Yet somehow, I managed to run injury free for the almost 2 years I ran in that model. The same was true for all of my teammates. There were “luxury” trainers available from Adidas or Pumas. But, most of our pennies were saved to buy the spikes needed to race on the cinder tracks we had in that era. Meanwhile, the road racing groundswell was in the making. Distance Running news became Runner’s World Magazine. Bill Rodgers and Frank Shorter were the pied piper icons to fuel the emerging running boom fire. In the late 70’s RW did their first comprehensive shoe review. A human performance lab did several physical characteristic tests. Based on this data, the shoes were ranked from one to five stars. The idea was innovative and with good intentions. But we all know that many times the road race to hell is paved with good intentions. Sales of 5 star shoes skyrocketed while excellent shoes that didn’t test well were ranked 1 or 2 stars and were suddenly discontinued. For example, one test in the study measured absorption of energy of a weight dropped onto the heel of a shoe. So, here is the classic en vitro versus en vivo scientific principle. Measurements in the test tube in the lab do not reflect what is happening in the real world. This only measures initial impact in the shoe and says nothing about the angular velocities and peak and sustained forces on tendons, muscles, bones and ligaments in the human body. Shoes that were not right for many people flourished and led to the nuclear arms race of which company could produce the biggest attenuation of the initial impact force.

Dr. Daniel Leiberman’s recent studies point out that heel strike causes an initial impact transient, a nearly instantaneous and large increase in force that occurs as the heel comes to a sudden stop upon impacting the ground. The shoe reduces the force by about 10% and slows the rate of loading considerably. This, in addition to distributing the impact force over a larger area of the rearfoot, makes it comfortable to exaggerate heel strike leading to the en vivo stress on the human body.

Shoe reviews do not shoulder all the blame. The consumer who is enthralled with the latest gimmick fuels the diversion away from what is really best for them. Back in the 60’s, Keds had the magic wedge which “make you run faster and jump higher.” It quickly became apparent to shoe companies that you put an untested gimmick (a few weeks use by a wear tester at best) on the market. The Nike “air” is classic example of this. It was sealed gas tubes enclosed in a polyurethane midsole. The Tailwind was a successful selling shoe even though instability injuries were rampant with the shoe. The Columbia attempted to address this instability by added a more stable EVA, but like the spaceship Columbia in its ad, it too, crashed and burned. It took several renditions of the air gizmo before the bugs were worked all. If the consumer wasn't so willing to be the long term ginea pig for an idea they like, gimmicks and gizmos would be an insignificant factor.

Running shoes are supposed to protect the foot. However, running shoes are also a business. They are mostly part of huge publicly traded companies whose concerns are market share, sales, net profits, free cash flow, and everything that goes along with a myopic shareholder quarterly report.

This adds pressure to have shoes on the minimum number of lasts to accommodate the maximum number of people. Many companies copy another company's best selling lasts. This leads to less variation among the brands and even less models to address the subtle genetic diversity in all the feet out there. Not only at the corporate level but also the retail level where stores have only so much capital to stock their shelves. Improper fit leads to abnormal function.

Now add to the fact that Sport Trend magazine did a survey study in the late 80's and found that 80% of the running shoes purchased will never even be used for running.

You can see reasons for wayward goals and distractions of the health quality of running shoes. This is why the barefoot running community knows that unshod feet often outperform the latest couple hundred dollar smart shoe.

The Great Red Hope

2010-02-12T16:25:00.000-08:00

A recent experimental treatment for tendinosis was found to no more effective than injecting salt water.

The hopes of many were raised when the media put forth articles such as these:

http://www.nytimes.com/2009/02/17/sports/17blood.html?ref=health

http://www.nytimes.com/2009/08/20/health/nutrition/20best.html?_r=1&src=twt&twt=nytimesstyle

It sounds seductive to take extracts of the athlete's own blood and inject them into the injured area to heal an injured tendon. Most chronic tendon injuries are as a result of a complex process called tendinosis. So what is the cliff notes version of tendinosis? The suffix "osis" implies a pathology of chronic degeneration without inflammation. The main problem for someone with tendinosis is failed healing, not inflammation; tendinosis is an accumulation over time of microscopic injuries that don't heal properly. Although inflammation can be involved in the initial stages of the injury, it is the inability of the tendon to heal that perpetuates the pain and disability. Most of the pain associated with tendinosis probably comes not from inflammation but from other irritating biochemical substances associated with the injury. Biochemically, it is the replacement of injured tendon collagen with the wrong kind of collagen. Normal tendons and ligaments consist mostly of Type I collagen, with smaller amounts of Type III collagen. When you get tendinosis, some of your collagen is injured and breaks down. Your body tries to heal the tendon, but when you have chronic tendinosis your body doesn't repair the collagen properly. The tendon loses its spring like characteristics which triggers more abnormal forces in a degenerating vicious cycle.

I know of many a recent athlete that opted for this procedure, which is not covered by medical insurances, only to have found they wasted valuable time and money.

The results of this double blind study are discussed here:

The new study included 54 people with chronic Achilles tendinopathy who participated in an exercise program to stretch their tendon while contracting their calf muscle. The exercise program was coupled with either a PRP injection or a saline (dummy) injection. Researchers measured pain and activity levels using a standardized tool at baseline, 6, 12, and 24 weeks.
Although there was an improvement seen among individuals treated with PRP after 24 weeks, it was no different than what was seen among those who received the placebo injection.

http://www.webmd.com/fitness-exercise/news/20100112/new-achilles-tendon-treatment-falls-short-of-hype

So what is a poor injured athlete to do? Surgery does work but takes 1 to 3 years to get "back to form." Keep in mind that "form" is slower than the pre-surgery form. I find the best option is to start with off-loading the tendon. A special tape is applied every 3 to 5 days to reduce peak forces in the tendon. Varying amounts of eccentric strengthening exercises are also helpful. Cortisone type steroids are a complete no no for this problem. However some people gain benefit from injection of an extract form the Arnica Montana plant. Then identify the hidden causes the are overloading the tendon. This takes a thorough, analytical, and diligent sports medicine physician. If you could do it yourself, you wouldn't be at this level of chronic injury, now would you?

Fighting tendinosis is a complex war, not a single battle. There is no magical silver bullet. So use all the resources at your disposal and increase a victorious outcome.

Rest in Peace Larry Olsen

2009-12-08T16:21:00.000-08:00

The sun sets on a kind soul
I have called my friend.
For what seems like forever,
and now it is.

They say running is a loner sport
but they are not runners
For if they were, they would know
that every excursion is a group run.

Our friends are there over our shoulder
to set the pace and keep us strong
to strive...to dream...to laugh...
to live...to run, today.

I now hear the hollow sounds
of my own steps in stride.
For a special one in thundering herd
is now more distant.

Ambling Barefoot

2009-12-03T18:43:00.000-08:00

Barefoot running has been around for awhile, but did not hit the national radar screen until the best selling book Born to Run by Christopher McDougall put a new face upon barefoot running interest. You know things are reaching a critical mass on this issue when non-runners start to bring articles about this to me in my office. Minimalist equipment, such as the Nike Free, Tera Plana, and more recently the Vibram Five Fingers (a glove for the feet) are gaining fans and market share.

This past week I received the following position statement from my National Professional Society:

APMA Position Statement on Barefoot Running

It is a very non committal statement leaning against unshod running. Some of the academy members were more critical: "Most of my patients aren't world class runners," adds foot doctor Stephen Pribut, DPM of the Academy of Podiatric Sports Medicine. "It wouldn't make sense for them to risk getting twigs and glass in their feet. And I think some soft surfaces increase plantar fascia and Achilles problems. Of course, what doesn't kill you might make you stronger."

Running surface conditions that are too soft can pose a risk to the shod as well as the unshod runner. Barefoot running can benefit the weekend warrior as well as the world class runner because I know of no class of abilities who doesn't want to have a smaller number of injuries. I only hope Dr. Pribut was quoted out of context. I see less plantar fascia and Achilles problems when bare feet meet the turf.

My first experience with barefoot running was at an AAU developmental track meet in Paramus, NJ. I was speaking with World Class marathoner Tom Fleming. My shin was stiff after winning a 3 mile race and he suggested that I warm down barefoot on the grass. I did so, but for some reason, never incorporated this maneuver into my routine. Now fast forward about 35 years. I am invited to participate in a semi-private thread by National Distance Running hall of famer Patti Catalano Dillon. I am there no more than a week and the barefoot running questions from Camille Herron get put to the foot doctor. I didn't have many answers so I did what any objective inquisitive runner/physician would do. I experienced it. Four years later, it has become an important tool in my running bag of tricks.

For the record, here is how I do it. I do not run barefoot on the extremes of surfaces, no roads and no beaches. I just gradually build up the barefoot miles to about half of my run. I find the best place in the urban/suburban environment is on AstroTurf. The consistency is perfect for running. The fields are swept of objects often with a "Zamboni" type contraption. Ironic, isn't it? The best place this lover of scenic trails runs to amble au natural is on an artificial surface.

There are some very compelling arguments for going shoeless, or at least wearing the least amount of shoe possible.

You may develop a more natural a fluid of gait. Sometimes I am so fluid, running takes on a Zen like enjoyment. This can only be proven in a subjective fashion by actually trying some unshod running.

It is the belief of this author that the biomechanics of running is cleaner. There is less errant eccentric and postural muscle firing during the gait cycle. Tendons have in excess of 90 percent energy return. Mid soles of running shoes have considerably less energy return so they impair rather than enhance function. Aging of the shoe materials causes even more loss of support and energy return.

So my national society feels there is a dearth of studies, abstracts, and reviews
available on shod versus unshod. It took me all of one hour to find a bunch. Here are some highlights:

Wearers of expensive running shoes that were promoted as correcting pronation or providing more cushioning experienced a greater prevalence of these running-related injuries than wearers of less expensive shoes (Robbins and Gouw, 1991). In another study, expensive athletic shoes accounted for more than twice as many injuries as cheaper shoes, a fact that prompted Robbins and Waked (1997) to suggest that deceptive advertising of athletic footwear (e.g., "cushioning impact") may represent a public health hazard. Anthony (1987) reported that running shoes should be considered protective devices (from dangerous or painful objects) rather than corrective devices, as their capacity for shock absorption and control of over-pronation is limited.

Michael Warburton: Running barefoot is associated with a substantially lower prevalence of acute injuries of the ankle and chronic injuries of the lower leg in developing countries, but well-designed studies of the effects of barefoot and shod running on injury are lacking. Laboratory studies show that the energy cost of running is reduced by about 4% when the feet are no shod. In spite of these apparent benefits, barefoot running is rare in competition, and there are no published controlled trials of the effects of running barefoot on simulated or real competitive performance.

When you run barefoot, your body precisely engages your vision, your brain, the soles of your feet, and all the muscles, bones, tendons, and supporting structures of your feet and legs. They leap to red alert, and give you a high degree of protection from the varied pressures and forces of running.

On the other hand, when you run in socks, shoes, inserts, mid soles and out soles, your body's proprioceptive system loses a lot of input. "This has been called 'the perceptual illusion' of running shoes," says Warburton. "With shoes, your body switches off to a degree, and your reaction time decreases."

So what are the risks? There is obviously less protection of the running bare foot. Ironically, my only pedal puncture wound ever sustained happened while running with running shoes on my feet.

So my society wants something conclusive? You cannot do a double blind study on something like this so results will always have some level of bias.

Abebe Bikila famously won the Olympic Marathon after discarding the shoes given to him before the race by a show company. Most Ethiopians I have treated have a "boxy" shaped foot. I am sure that the shoe company made he gaffe of giving him a shoe made on a traditional last for a western foot. The misfit was resulting in discomfort so Bikila went back to the known quantity or running barefoot like he had trained in his homeland.

Running barefoot is a healthy alternative to running shod. The educated runner will encounter minimal risks and great benefits. The funny thing is that if shoes met the individual needs of the runner in a better fashion, this whole shod versus unshod discussion would become a moot point. However, that is a whole other rant for another day.

News Flash

2009-11-07T16:22:00.000-08:00

I will be lecturing at the annual meeting of the Tri-Valley Frontrunners this Thursday in Milford, MA. The talk will take a fresh look at the real causes, the science, preventitive pearls and assorted treatments involving running injuries. My style is to entertain as well as to enlighten. I hope to see some of my blog readers there. Feel free to get in touch with me if you are part of a group or club that wants such a talk.

Ilio-Psoas Syndrome

2009-05-24T14:28:00.000-07:00

IP syndrome is likely the most underdiagnosed ailment in runners. The likely reason for such underdiagnosis is that both patients and clinicians tend to focus in on the effect (pain) than the cause. The syndrome, as it occurs in distance runners, starts as a loss of function with little to no pain. Then it shows up as secondary problems in other areas of the body. A common early complaint with this malady is that it seems more difficult than usual to get going in the early part of a race or workout.

The hip is a ball and socket joint which allows for 3 planes of freedom. Range of motion (ROM) of the hip includes approximately 120° of flexion, 20° of extension, 40° of abduction, 25° of adduction, and 45° each of internal rotation and external rotation. The resting position of the hip is considered to be 30° of flexion and 30° of abduction.

The ilio-psoas is actually two muscles. The psoas and iliacus muscles originate from the lumbar spine and pelvis, respectively, and are innervated by the first three lumbar nerve roots. These muscles converge to form the iliopsoas muscle. The IP inserts onto the lesser trochanter of the proximal femur. The psoas major tendon exhibits a characteristic rotation through its course, transforming its ventral surface into a medial surface. The iliac portion of this tendon has a more lateral position, and the most lateral muscle fibers of the iliacus muscle insert onto the lesser trochanter without joining the main tendon.

The iliopsoas muscle passes anterior to the pelvic brim and hip capsule in a groove between the anterior inferior iliac spine laterally and iliopectineal eminence medially. The musculotendinous junction is consistently found at the level of this groove. The iliopsoas muscle main function is as the prime mover of hip flexion. This is of utmost importance because hip flexion is the drive behind a distance stride. (Also, it is an external rotator of the femur). So when this muscle starts to lose strength, power or flexibility, the muscles that assist in these actions often feel the brunt manifesting in injury. Loss of hip flexion leads to hamstring injuries. Loss of external rotation leads to sciatica and associated hip injuries.

With all this anatomy, physiology, and kinesiology available, one would think that hip function would be utterly predictable and relegated to boring academic trivia. In fact, this is far from the truth. With each and every change in hip position, muscles change the force they apply on a joint. Sometimes even a small change in position can cause a hip muscle to have a completely opposite function. Put another way, a muscle can be an internal rotator of the hip. Change the position of the hip a few centimeters and it is now an external rotator of the hip. For this reason, it is not unheard of for seeming contradictory injuries including the knee, calf or even back problems to result from this syndrome.

Diagnosis is best done with a clinical “hands-on” exam. X-rays are always negative for findings of IP syndrome. Sonograms may assist with diagnosis but are rarely diagnostic by themselves. MRIs are most helpful of any imaging tests. Hence, much of the needed information to determine treatment course is supplied through the clinical exam.

Treatment starts with the basics: Rehab the deficient muscle functions. If the muscle is weak, strengthen it. A type of crunch is a good tool. A common mistake is to do a traditional crunch which emphasizes concentric strengthening at the expense of eccentric strengthening. There are variations that can customize these exercises for distance runners and individual needs. If the muscle is tight, stretching is paramount. The lunge is an effect maneuver, so long as it done properly (many people stretch the psoas fibers at the expense of the iliacus fibers). Also, long standing cases need to have stretching and the scar tissue freed up before strengthening become effective.

The path less traveled

2009-04-14T18:09:00.000-07:00

"TWO roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth"

One of life’s crossroads came in junior high school for me. My main extracurricular activity was band. I played in the band or at least was the source of the band conductor’s indigestion with my very mediocre performance. Only the best made Jazz band. My goal of saxophone in the Jazz band was just a pipe dream or should I say a reed dream. There was something about the blue note that struck a chord with me. My problem was the John Phillip Souza sour notes that blocked the way to that goal. I turned down the less traveled path of running that early spring over 40 years ago. My foot steps still grace that path.

Last week I went to the Cohasset by the sea Road Race. I cannot believe it has been 30 years of one race for me. It feels like I am living a remake of the movie Same Time Next Year. I guess life does imitate art. But, a good race has a way of drawing one back. The time of year kicks off my racing season (especially as age and race less often). The course is beautiful. It goes by quaint inlets, spectacular ocean vistas, mansions of the rich and famous, and historical points of interest. The course is challenging. Challenge inspires my gumption more than a flat fast “PR” course. The race is well run year after year. Every turn is marked and every split is barked out loud, clear, and accurate. The post race festivities (food, times, awards, etc.) are prompt and efficient. Then there is the legacy effect. Each year insidiously adds to its momentum. It seems to add to the tall tail legend effect, as well. I noticed that I was being credited with “5 or 6 wins” when in fact it is more like 3. At this rate, I can expect to be credited with 42 overall wins when they run the 40th annual in 7 years.

About 1,500 runners lined up on this sunny but very breezy 57 degree day. While waiting for the race to start, someone tapped me on the shoulder and introduced himself. It turned out to be my paperboy from the early/mid 1980’s. I had given him a shirt I got from famed miler Steve Scott as part of his newspaper Christmas tip. I remember this young boy reacting like I had given him a leprechaun’s pot of gold. He went on to become quite a middle distance runner. I wonder if my gift had any influence on his path. He then says that he will be shortly entering the masters division. Now I just feel real old rather than philosophical.

I ran a time of 37:23, a respectable time for someone about to turn 55. I particularly enjoyed this years Cohasset by the sea 10K. I felt good. I also had the surreal experience of many past positive and memorable moments merging into one nostalgic point of time. I won the race three different times today. I was also top 5 a gazillion times more. I ran mid 31 minutes like I did in my heyday. My picture crossing the finish line graced the cover of the Cohasset phone book afterwards. It was 90 degrees. It was 33. It was raining cats and dogs. There were small dogs flying off the ground (one year a small dog not on a leash dashed out from the narrow funnel of people right at the finish line. The race director hooked it with his foot a half stride in front of me barreling down the chute, sending it back into the crowd. All I saw was the poor pooch come from the bottom of my field of vision and take off like superdog out the upper right of my field of vision. Dog was startled but apparently unhurt. The same was true for yours truly).

So, I look forward to next year at my annual rite of spring, the Cohasset by the Sea Road Race and hopefully many more.

I topped the day off by going to a monthly jazz concert in Weymouth. Don Altobello and his group put on a fine show at Hajjar’s restaurant. It is stellar music of the style I always wanted to play. For a couple hours, the musical idioms help me slip into a musical bliss. Time again becomes non linear. I revisit that fateful divergence on my life’s path all over again, one that has made all the difference.

Ask Dr Bob (#3)

2009-03-15T06:37:00.000-07:00

A reader writes: A friend of mine said I could be nailed by the USTAF for drinking Brigham Tea. It's just an energizing tea I buy in my local health food store. I say he's the one who's high for thinking I can be nailed for tea from a health food store.

Drugs, Sex, and Rock 0' Roll

Dear DSRR,

You can't get no satisfaction from me.

Your pal's right. I hope you didn't have a big bet riding on this one. Brigham Tea contains Ma Huang, which is Chinese Ephedra. It is a natural source of Ephedrine. If you drink that stuff before a USTAF event and you are a USTAF member, you can be subjected to a random drug test. It is not just my imagination getting in the way. The Ephedrine will show up on the test and put you in the banned in Boston. (and everywhere else) ranks along with Mary Decker- Tabb-etc-Slaney. While you're riding out your suspension in the Penalty Box, maybe you can meet her. She must be due for another hubby soon. Then she could become Mary-etc-Drugs, Sex and Rock '0 Roll. One consolation will be you be having fun, fun, fun after the USTAF takes your T-card away.

Ephedrine is not only illegal in organized running, it is also dangerous. Several heart failure deaths in the Boston-metro area have been attributed to Ma Huang in recent years. Now that's a stairway to heaven! Ma Huang is also the main ingredient in Mormons Tea,. Miners Tea, Bishops Tea, Teamster Tea, (so that's how they got rid of Jimmy Hoffa), and Squaw Tea. Similar (and also banned), substances are found in over the counter cold preparations. Some examples are Actifed, Drixoral, Dimetapp, Cantac, Allerest, Vicks Inhaler, and the beat goes on! Read labels! Phenylephrine, Phenylpropanolamine, Psuedoephedrine, Propylhexedrine, and Desoxyephedrine will all have you doing the Jailhouse rock. So, if your cold preparation contains any of these, you will be left out in the cold by the USTAF. You don't have to be on Cloud 9 to get banned from the long and winding road. Choosing a cold preparation you can use will be like stepping on eggs ... but its far better than UST AF getting into regulating Steppenwolf. Please don't ban my devil with the blue dress on. For if they start to regulate sex and rock 'n roll, we'll all become drifters from the sport.

Dr Bob (and the medicine show)

Biting Winter

2009-02-15T17:29:00.000-08:00

I have frostbite all over where the tope of my foot meets my leg. So basically, the skin is all dry and/or dead and it burns at times. Do you know how I can get my skin back to normal?-- Cold Feet

Dear CF,

There is no subsitute for a real examination. However, my cyber shoot from the hip pocket gut feeling is that it doesn't sound like frostbite. Bite makes me think of that Pennsylvania groundhog. If he sees his shadow, its 6 more weeks of winter. If he doesn't see his shadow, its an early spring. Well, Phil the groundhog bit the mayor, this year. I guess that means we are going to have a biting cold winter.

Considering that it really has been a biting winter, you probably have Chilblains (pernio). It is self-limiting problem that does not result in permanent damage. It sometimes becomes chronic (produces long-lasting symptoms) if you get hypersensitivity to temperature changes. No treatment is known other than trying to prevent the front of your ankle from cold exposure. Wear tall thermal socks and running pants that do not expose your ankles to the elements. Tapered pants or tights are effective thermal barriers. Leg warmers used by dancers are also very effective. If your condition does not improve as the weather moderates, have a medical examination.

Millennium Musings

2009-02-01T16:19:00.000-08:00

I would like to extend a belated happy new year to all my readers. I would also like to share an article I wrote for my running club newsletter written on New Years eve, 1999.

The clock ticks methodically towards midnight on New Year's Eve. To some it is Armageddon of religious prophecy. To others, it's Silicon Valley Armageddon with Y2K bugs buzzing in civilization's ear. To me, it is just another night of lasagna and fine wine at home to usher in make-a-resolution-to-break-next-week day (or I will write the updated year on my checks day). I refused to bring in firewood from the woodpile for our fireplace. My better half said it had nothing to do with Y2K but that more drunks hit telephone poles on New Year's Eve than any other night. Well, she never had me bring in firewood on any other New Year's Eve. Still, I can't help but ponder whether my tension level should be higher than “Hey mon, don't worry…be happy.” I remember pondering about the year 2000 when I was a child, (jeez, I'll be old then), and what the world would be like. I also remember reading about Haley's comet, which would make its next pass near our planet around that time (neat, I really want to see that). I also vaguely remember being in a battle for my life at age 6. I had rheumatic heart disease twice by that time and spent most of my first grade hospitalized with a failing heart valve. My hospital stay at River Dell Hospital coincided with Dr. X, (as he was known on national news). This Doctor Death, as I called him, went around the hospital killing patients with curare. Fortunately, I missed his wrath but had the sequellae of my illness to deal with. Since I nearly died on strike two, strike three would be fatal. My parents were given instructions to have me take preventative antibiotics for the rest of my life and to not stress my heart. “His heart won't have the physical tools to handle exercise.” For a child that means no play. I penciled in a lot of Venus Paradise color by number pictures and read a lot of astronomy and geology books on a cot that was moved into the backyard on nice days.My life changed when a man who was deemed by the “wise men” of baseball to be too short, too stocky, and too slow to ever play professional baseball hit the scene. Spring training flash in the pan they said. He'll be gone before July. I remember seeing Pete Rose in the old Polo Grounds in New York City against the Mets. The game was won with a 10th inning homerun by Art Shamsky, (who?), but Pete kept his team in it with hits, runs, and plays that never end up in the box scores. In a post-game interview, he dispelled his critics by saying something to the nature of focus, a lot of practice and 110 percent effort can overcome a greater skill level. If this star baseball player could prove the experts wrong, so could I. So a journey of a thousand miles began with a single step. I first imagined I was playing baseball for Pete Rose's team by bouncing a ball off the back steps of our house. With each passing day, I threw the ball harder while running, diving and lunging for the increasingly errant bounces. Soon, the imagined game became real effort. No longer would I be denied exercise. My crazy play was exercise! I soon won my parents and doctor over to my side. This was good because I failed every team physical involving a stethoscope and needed letters from both parties to fight for my re-installment. By junior high school, I was ready to go out for a sports team. Basketball was my passion then but I chickened out with a steady barrage of too short, too thin, and too slow even though I out played some of the future team members in pickup games. I chastised myself for ignoring Pete's creed and vowed to go out for the track team (at least, nobody gets cut from that team).Our first meet ever was against local powerhouse, Bergen Catholic. Their team filled 3 school buses. They warmed up in a single file line one stride apart that was a quarter of a mile long. I was our second string miler (of 2 runners) lining up in 3 rows of BC runners. I don't know what got into me when the gun went off. I bolted for the front and “never looked back.” The first quarter was in 65 seconds, 10 seconds faster than my PR for that distance. Bets were flying on the sidelines as to how much further I'd go before I would double over in a heaving ball on the track infield. Well, it never happened. I held on to win in 5:04 by a 100-yard margin over the second finisher. We lost the meet 89-6. I went from bully fodder to celebrity but only Pete Rose and myself knew the real victory that was won that day.

It was cloudy every night of Haley's comet close pass to the earth. Still, I got up in the middle of the night to check the sky anyway. A boyhood promise had to be kept. On the last night it was to be visible with the naked eye, I woke up at 3 AM to a sky that was sparkling clear… and a blustery 8 degrees (a March 12 record). I bundled myself up and drove to Duxbury beach, a recommended viewing point. I arrived to disappointment. The only cloud patch in the whole sky was over the comet. Still I persevered. I'd stay till dawn if I had to. Then I heard a voice from the pitch-black beach. “Want to see the comet? My telescope has a special lens to see through clouds,” said some kind gentleman. I nodded and took a gaze. “It's not a great view. It kind of looks like a 30 watt light bulb in a dirty fish tank,” he joked. “It's great light to a six year old boy,” I replied to a now confused man.It was October of 1999 and I watched on TV as Pete Rose was honored for being chosen to the All Century Baseball team. The standing ovation he got outshone all of the other team members, including hometown hero Henry Aaron. I think this happened not so much for his accomplishments in his sport but to celebrate his moral victory. The man Pete bested for the hit record purposely sharpened his spikes to hurt people and was so bigoted that he should have worn a white sheet rather than a baseball cap. People have committed far worse deeds and atrocities. Putting a wager on his team to win pales in the face of murder, rape, and snuffing out the hope of our youth with drugs. Yet a man who gave gifts to groundkeepers and towel managers to show his gratitude for a kind word and a job well done is not even allowed in the parking lot of any baseball game.

Well, the first has come and gone. No bugs, no devils, no (computer) errors, and no terrorists left on base. But I knew that yesterday. Armageddon doesn't choose a nice round number. It's something we confront daily. It was there at age 6, in junior high and on that frigid dark beach. Through focus, practice, and 110 percent effort the greater skills of bad luck can be overcome making the goals we achieve so much more special. No, 2000 is just another step along that journey of a thousand miles.

Battle at Wounded Knee

2009-01-09T18:31:00.000-08:00

Dear Dr. Bob

I'm hurt. My left knee was bothering me all week, but as soon as I started running it would be fine. The pain would come after a run, and I just put it down to the hard hills of America's Wild West. However, after a particularly grueling uphill run on Saturday, it hurt like crazy all night and the following morning. Sunday I lasted about two strides. Walking down stairs is particularly difficult. I put ice on it last night, and will continue to do this throughout the week. I'm sure I need new shoes but wonder if I have done some lasting damage? With my past experiences, I've lost some trust and faith in doctors and tradition medicine

Kneed Help

Dear Kneedy

It was one of those unceremonious events of "How the West was Won." Broken trust and empty treaties fueled the human darker side and led to a Nazi style genocide on that late December day where men, women, and children lost their lives in a hail of machine gun and rifle fire. Some were pursued as far as two miles then run down in this "police action." One hungry infant was found trying to nurse from her lifeless mother's bloodied breast. The soldiers were given the Congressional Medal of Honor for this embarrassing chapter in our history.

As for needing my help, it sounds like you have patellofemoral syndrome (previously called chrondromalacia or common name, runner's knee). As with all running injuries, it is not the name and location of the injury but identifying the underlying causes and tailoring the treatment to address those causes.

The most common factors contributing to this injury are:

1. Tight muscles (specifically the quads, hamstrings, IT band and the gastrocnemius). Mr. KH, I have seen your quads in person, so I know they are so tight they look like you have been using Viagra ointment instead of Ben Gay. I don't care if they have always been tight. All I know is that your quads are pathologically tight. Maybe they have always been tight but became even tighter repeatedly running the hills of Corbett Canyon.

2. Weak muscles (quads, hams, and IT band). An interesting thing happen when you are forced to rest. Muscles atrophy with disuse. When the quads become shrinking violets, the lever arm of the IT band decreases, making the muscle unit overwork. The end result is IT band tendonitis or patellofemoral syndrome. Either injury will get worse rather than better with rest.

3. Bad biomechanics. For example, if the subtalar joint is too pronated while the foot is on the ground. This causes the talus to go down and in. Since the ankle joint is mostly a one plan hinge joint, the whole leg rotates inwards to compensate. This translates to an improper tracking of the kneecap. This discongruency of the knee is measured as a high Q angle...and no, I did not say you have cute angles.

4. Bad running shoes. This can be poorly designed shoes, defective shoes, worn out shoes or ones that are plain not a match for your foot.

5. Previous damage to knee structures. You are walking in the city and a voice says "stick 'em up!" You know Tae Kwan Do so you deftly swing your elbow back but contact nothing but air. Then a midget blows off your kneecap with a Saturday night Special. All kidding aside, a meniscal tear, a Baker's cyst, genetically inherited ligament laxity and an old untreated ligament sprain are common causes in this category.

I may sound like a parrot here with this repetitious phrase, "awwwwk, Polly want a treatment?" However the best treatment is to focus on alleviating the cause. The treatment may include straps, braces, foot supports, and a multitude of stretching and strengthening exercises. Conservative care is by far the best answer. Surgical shaving of the back of the knee cap has an extremely poor success rate (about as good as outrunning the midget's bullet).

First and foremost, develop a trustful relationship with your health care provider. The practitioner should be worthy of this trust if he/she takes a detailed history of your problem, does a thorough examination focused on the appropriate systems, and informs you of the findings before ever commencing treatment. Sometimes the cause is obvious. Sometimes these factors are more occult and take multiple visits. Work with your doctor. Bring notes. Bring all your shoes and any gadgets you use. A good one will take to the challenge the same way you look at an important road race.

KH, you remind me of a guy I'll call George, who went to church every day and prayed to the Lord to win the lottery. After 6 months of this routine, his faith and trust were ebbing. He prayed again, questioning why if He existed, the Lord of the Universe would not answer his prayer. Then, all of a sudden, there was a brilliant light and a booming deep voice, "George, I hear your prayers, but can you just do me one small favor?""Anything, Lord!" George replied."George, could you at least buy a lottery ticket?"

KH, your lottery ticket is forming a positive relationship with the professional that is trying to help you. Do so before you become a modern day victim of the Massacre at Wounded Knee.

Chemin du Buttereau

2008-11-29T05:15:00.000-08:00

(Please click on each picture for a better view)

Longevity in the distance running is intertwined with heavy doses of health, luck, and spirit. Longevity is something I have been blessed with in this sport. I have been running for 40 years and have won races overall in 6 different decades

In this post, I will share a source of my spiritual renewal. It is a running course I call Chemin du Buttereau (or just Chemin for short) after the Cape Breton Highland National Park trail that makes up the bulk of the course. The course starts right in front of the modest cottage I own in Petit Etang, Nova Scotia. Within one minute of running along the Cabot Trail you enter the national park running over a bridge crossing the Cheticamp River. A quick swing around the park visitor center and you go through the campground. Back to the Cabot Trail for a 150-200 meter section around a pond. Now you start the well groomed hiking trail called Le Chemin du Buttereau. The trail climbs for a couple hundred meters. It then follows the river in rolling fashion shaded with assorted glimpses of river, emerald colored delta islands,beach and ocean. Once you reach the mouth of the river at the ocean (Gulf of St Lawrence), there is a one kilometer loop that I never tire of, physically or spiritually. The waves thunder majestically against the cliff on the ocean side. I often see whales in the water here.

Eagles glide apparently motionless in the thermals above this spot. The meandering course of the river on the riverside has water that glistens like silver in the daytime sun. Troubles melt away. The only decision that has to be made is how many kilometer loops shall I run today.

It is the only course I have that I get a sense of disappointment when I turn back home rather than add another loop. The course is challenging but not so challenging that you couldn't run it on many consecutive days. The footing is of speed work quality. The trail isn't the only good scenery on the run. Here is the campground road only minutes from home.

When I had cardiac problems a couple of years ago and thought running might become a thing of the past, you get a feeling of loss. It was not the loss of racing skills that hit me the hardest. The thing I mourned most was not being able to run Chemin. This is when I realized the value of priceless intangibles I already had.

The cardiac problems cleared up. I am back to racing and more importantly, back to Chemin. My first run on this course of every trip now starts with a Rocky-like arms in the air exultation when I reach the river ocean junction. This new crazy running ritual will no doubt last as long as I am able to run.

The Myth and Matter of Achilles Tendonitis

2008-11-22T15:19:00.000-08:00

The Achilles tendon is the thickest and strongest tendon in the human body accepting the equivalent of 6 to 8 times body weight with each stride . It is located where the two heads of the gastrocnemius and one head of the Soleus come together to form a cord-like tendon called the triceps surae. This musculo-tendinous unit crosses three joints and exerts meaner force on all three of them than a junkyard Cerberus. The tendon inserts into the middle part of the posterior surface of the calcaneus, a bursa being interposed between the tendon and the upper part of this bone. No other muscle group in the human body exerts such influence, making it the stuff of myths and Homer's Legends. Doh! Not that Homer, but the one of Iliad and Odyssey fame.

Modern day myth starts right with the diagnosis. I feel like Sisyphus when people talk to me about Achilles Tendonitis. Most cases of injury in the back of a runner's heel turn out to be Achilles tendonosis. There is no actual clinical inflammation in the tendon nor are inflammatory cells found in biopsy samples. Hence, tendonitis is a misnomer. Tendonosis is due to chronic degenerative changes in the tendon from repetitive microtrauma and tissue overload.
Achilles Tendonitis does occur; however, I will be making orthotic devices for a Minotaur before the number of "itis" cases overtake the number of "osis" cases.

The etiology of this condition is complex and multi-factorial. It includes:

Gastrocnemius or soleus muscle fiber injury. Muscles fire basically in three ways and hence can be injured in three different ways. The shortening action of muscles is called concentric firing. You fire the Achilles complex concentrically when you raise your foot at the ankle on a step. The breaking action of muscles is called eccentric firing. Many people are 'Zeus lightning bolt shocked' when I tell them that dysfunction/injury of this type is most common. The muscle fires to slow down the lengthening of the muscle. It is a decelerating or braking type action of the complex. The Achilles complex does this shortly after your heel makes contact with the ground during a running stride and does this for only the first half of that split second the foot is on the ground. Postural is the third type of muscle firing. It is the subconscious postural firing of this muscle group that keeps you from falling flat on your face while standing. A muscle can have injured eccentric abilities but not concentrically (or vice versa). The same relationship goes with postural versus the other two.
Structural weakness is common at any tissue change. Tendons are arranged in parallel fibrils. Any knick in the tendon can cause longitudinal tearing along these parallel fibril planes.

Lack of Flexibility can play a role in the early stages of this problem but rarely in the late stage. For this reason, stretching makes a poor universal treatment. Many later stage tendinosis patients are made worse by stretching.

Sometimes tightness is not in the muscle fibers but in the golgi bodies and other parts of the tension monitoring systems within the musculo-tendinous unit. These problems will not respond to traditional stretching and require a different type of exercise.

Bad Shoes: Old shoes, defective shoes, and models that are not a match for your foot type can all put abnormal levels of stress on the tendon.

Bad foot biomechanics: Surprisingly, this is a rare cause of tendinosis in my clinical experience. It occurs when there's too much of a certain motion in a foot joint, or if the right amount of motion occurs but at the wrong time. Fortunately, it is easy to fix when this Pegasus of a different color does occur with use of a custom foot orthotic device.

The shape of your heel bone: A prominent bump on the back of the heel bone leads to more wear and tear of the tendon. Poorly shaped subtalar facets lead to the biomechanical stresses mentioned above. The width of your Achilles tendon: Dr. Richard Schuster analyzed the data of over 10,000 of his athlete patients and found a statistical correlation between the width of the tendon and incidence of its injury. He found that thin tendons are more prone to injury.

Nutritional deficiency: Adequate amounts of Vitamin C are critical to tendon healing. Other deficiencies are more individual and open the doors to Hades with any further generalized discussion.

A Loss of ankle proprioception: Proprioception is the ability to know the location and position of a body part without actually looking at it. Loss of this ability has been implicated in all kinds of running injuries. This one is no exception.

Drug side effects: History of steroid injections into the tendon or general use of certain types of oral antibiotics (e.g. fluoroquinolones). It is well known that corticosteriod injections into the tendon may lead to tendon weakness or even rupture. Few people know that certain types of antibiotics can be a chemical Trojan horse for tendon injury.

Age: By the time we hit our mid 30's tendon tissue slowly starts to loose it resiliency. The number of mitochondria found in our cells reduce in number. Training effect and stress adaptation are slower to respond. This is a sad fact of life as to why degenerative conditions become more common in the second half of life. Age just has a way of making Icarus fly too close to the sun.

Illness: Diabetes, gout, and many other chronic diseases can and do play a role in this injury.

Genetics: Tendons mostly contain Type 1 collagen with a small amount of Type 3 collagen. This ratio varies from person to person as a part of genetic variation. Extra Type 3 is also produced during the tendinosis biochemical process. When the ratio of Type 3 to Type is higher be it from genetics or injury, tendinosis is at greater risk.

Improper amount of stress on the body part before adaptation. This has been called Overuse Syndrome. I hate that term as it leads to myths about exercise in general. The Achilles is stressed by running too fast, too soon. However, it would be a myth to think that Hermes-type speed is the only danger. It is also caused by running too slow. Too much hill training (up or down) can also cause adaptation overload.

Low back injury: Sometimes the heel hurts because of injury or function change initiated elsewhere. In my clinical experience, injury to the 5th lumbar, I st and 2nd sacral vertebrae, are the most common sites to trigger the tendinosis cascade.

Treatment is as diverse and varied as the causes of this malady. Each person needs a unique treatment plan. Rest becomes a four letter word to the runner when it comes to injuries ...whoops, it really is a four letter word' Nevertheless, rest does play a role in the healing of these problems in most cases. The length of time depends upon the severity of the injury. Rest can be complete-such as with a below knee splint or it can be done with partial rest. I prefer partial rest in most cases. My favorite method is to off-load the tendon with a carefully applied special type of tape that mimics tendon function. This allows the patient to continue some running, while avoiding muscle atrophy and increasing blood flow and anabolic processes that exercise stimulates so well. Partial rest can be a real win-win situation. Eccentric strengthening exercises come the closest to being a universal conservative treatment for the tendinosis condition. However, at the risk of being a repetitive Sirens' song, no long-term treatment plan will be highly effective unless you address as many underlying cause and risk factors as you can.

The Old Man and the Sea

2008-10-30T16:33:00.000-07:00

Danny, as promised, this essay in in honor of you.

An earlier time and version of me, I often heard phrases like, “runs with the grace of a deer” or “runs like the wind.” Once upon that youthful time, I was running alone on my high school track. A solitary old man was sitting in the stands. He limped slowly up to me after I finished my run, and said that he enjoyed the beauty of my stride. I stammered as I tried to come up with a response, but he interrupted and went on with passion in his voice. “I've seen many people run on this track and some quite fast. You don't run. You're visual poetry with the ground. It is a gift to be cherished. It makes the eyes and spirit of old men young again. It is the essence of life, I say. Never, I say never, give it up.” I really stared blankly now, not knowing what to say. The riddles seemed to shroud the compliments in an overwhelming way for a fragile young boy's psyche. I grabbed my sweats and went on my way.

It was 15 degrees, at best, on blustery February Sunday. Winds were 20 MPH gusting into the 30's slowing the pace of fast legs that have seen better days. It seems that, factors of aging aside and a bout with heart disease, it has become easier to let off the gas pedal of vigor and hide within my own comfort zone with each passing year. It is even easier when I can rest on past laurels. Reminiscing is easier than pushing the human limits of running. I questioned my own sanity for choosing this spot and on this day for a run. However, lunacy ruled for the day, as I headed directly into the wind to start the run. I distracted myself with the blue and green quilted waves with bright whitecaps that boldly crashed upon the beach. The horizon was so clear I felt like I could reach out and touch its delicate but definite boundary. The majestic display of nature helped to occupy the mind while the hamstrings cursed and screamed with every step into the head wind. My face was so cold, the sinuses ached. I broke the monotony and the chill by running one minute down wind before running 4 minutes further up wind. The only pleasure heading up wind for the four minutes was watching the seagulls and piping plovers that were hunkering down on the beach weave a pattern in the sky in front of me as they temporarily fled my approximate path up the beach. Just before the northerly turn-around, I saw a seagull who did not take flight. Instead it sat limp and drained with a stoic but determined stare. I soon realized it was sick, injured, or both. Death could not be but a few hours away. I felt a reverent pity for the poor creature's soul. I could not help but think that we will all be in that bird's situation one day.

I reached the turn-around point and relaxed my effort into the pleasant feel of a tailwind. I slowed my pace as I came back by the dying bird, wishing there was something I could do to make things better. Whatever great my empathy for this creature facing the end of life, I realized my powers over nature and the meaning of life were very limited. I looked back over my shoulder one last time to see the noble posture and courage in the face of death. My mind then flashed back to the old man at the track. The irony then dawned upon me that, if the bird could see how I have treated my gift, it might be having pity upon me. Be it a few hours or a few decades, be it disease or the slow march of the aging process, we do not die from disease, disability, and age. We live with them. Something happened to the embers of old sparks. My sun-faded jacket had an inner glow. I slowly upped my pace from the comfort zone.

It was Mark Twain who said, "Twenty years from now you will be more disappointed by the things that you didn't do than by the ones you did do. So throw off the bowlines. Sail away from the safe harbor. Catch the trade winds in your sails. Explore. Dream. Discover."

The trade winds pushed at my back. I concentrated on form. My pace continued to quicken as I explored, dreamt, and discovered.

Yes, you must have your ship boldly take on the wave in order to ride its crest. I want to try my best to get to the top of my own wave and touch the sky even if gravity and physics has lowered its watery mountain-size. The crest is the thrill. It is the essence of life. It is the thrill of the chase. It is Santiago catching his marlin. The prize is in the struggle. Yes, my eyes were starting to see with clarity. What can these old sea legs can do if given the chance? It is time to revisit the gift of stride, for that is how the spirit, once again, becomes young.

The Pit Bulls of Baskerville

2008-10-16T17:42:00.000-07:00

I wrote this piece as a question and answer column in the Tri-Valley Frontrunners club newsletter a few years back. It is a parable for a basic injury prevent concept. So the readers here can understand some inside information, valley girls is the self proclaimed knickname by the female members of the club. Also, Art Doine and Bobby Doyle were names of club members.

Hipper Chick: I have this pain in my hip. It started about six weeks ago and is so bad I cannot run anymore.

First it is Hip Chick. Now it's Hipper Chick. What is is about these valley girls and their fixation on hips. I'm lucky Linda Tripp didn't attend the meeting or I'd be answering Kenneth Starr's questions instead of yours. “Dr. Bob, were you involved with intimate conversation with a valley girl about her hip?” “No, I was not. She was having intimate conversation with me. Define conversation. Define hip!” Well, so much for impeachment. Let's get back to the fruit salad days of impeared hips.From grand jury interrogation of my own, I have deduced that this problem started right after christmas. Santa must have thought you were a naughty girl 'cause he left you a pair of Nike Lumpocoal Max. I also know the pain is located at the origin of the quadriceps muscles, a rare injury for runners. Combine new shoes with odd injury and I'd start my mystery solving with shoes. Here's why. New shoes can perpetrate the crime with unwanted model changes (just when you find a model you like....poof... it disappears), untested gimick features (like the arch cut-out that did my hamstring in last August), assembly line defects, and material variation. Assembly line defects are self explanatory. The untested gimicks subject is longer and juicier than the Starr Report. So for brevity's sake we'll focus upon material variation. To help us find out what is making your quad bay at the moon, we will go way back to another time and across the big pond to another place. I call upon mystery writer of purple past to help us, Sir Arthur Doine-an' (Bobby) Doyle.Enter, Sherlock Shoes! "By jove, Baby Watson, check out this EVA midsole I found in the moors." "It's without sole, sir," replied BW. "That's because I took it off, cheesecake head. What else do you see?" quizzed Sherlock. "It's damp from the moors, more or less," said BW. "No it is the hardness of the midsole. It differs from spot to spot. On the durometer scale it is 40 here and one inch away it is 36 and ... here right next to that spot it is 44!Darn that Dr. Morinjuriarity!" proclaimed Sherlock shoes. "Yeahand darn his dog, too!" hounds Baby Watson as he scrapes pitbull pasture patty off of his waffle trainers. Congratulations Sherlock, you've solved the mystery. We always assume the midsole and its pieces are of the same hardness as the specifications advertise it to be. In fact the industry considers a ten percent variation in EVA durometer to be acceptable. That's quite alot when you consider that midsole gimmicks to change foot function usually differ by no more (moor?) than ten durometer units. Now consider that there is no effective way for the companies to screen out even larger variations in EVA durometer other than random material testing. Therefore, some shoes make it to the market with subtle and invisible defects that interfere with normal foot function.So, now that we have a shoe-in as our suspect, how do we confirm his guilt. As Sherlock would say, elementary, my dear Watson. Switch back to an oldie but goodie. A pair of shoes you used successfully before the injury but not so worn out that it takes Sherlock's magnifying glass to find some tread on your corpse of a shoe. I know it is London rainwater past the dam but it is best to retire a pair of successful shoes half way through its useful life and keep them in your closet. If nefarious Dr Moreinjuriarity crops up, pull your Sherlock shoes out of the closet and wear them a week or two. If there is significant improvement or resolution, then your barking up the right tree. It is one great way to remove one variable from the injury equation.Hopefully, the mystery will be solved. Make sure you put your “Sherlocks” back in the closet where you can find them. For the fog and full moons of mystery will return. With all the shoe problems out there, Dr M and his demonish dog will have many an opportunity to howl in your backyard.

All that glitters

2008-09-28T06:32:00.000-07:00

I think everyone who partakes in an amateur sport, at some time or another, entertains the dream of running in an Olympic or world championship. I often did on days when I felt extra spunky on a run. It is just that I happen to also be a realist, even when I have my head above the clouds. Therefore, I rarely won, even in my dreams. Cracking the top ten was a fine and dandy doer even for a dreamer.

The idea to revisit cross-country in a big way started when Coach Bill Squires asked some of my workout friends and me if we wanted to run on a team for him in the cross-country Nationals to be soon held in Boston. Bill was between jobs and looking to showcase himself. He had been providing free coaching during the past two years for us, so it was the least we could do for him. He registered us with the USATF as Team SISU and gave us singlets with the team name. Sisu is a Finnish word which roughly translates to courage or toughness.....OK a closer translation would be balls! While waiting for my race, I watched Rodgers and few other people I know in the 1990 Masters XC championship race, thinking, I could do that. I could stay up with those guys (not yet realizing that age 36 is very different from 40+). So the seeds were sewn for a goal. Oh yes, I was about 200th place in the open championship.

Over the next three years, I trained hard but my heart really wasn't into it. I blamed it on the new duties of fatherhood rather than the physiology of aging. My times were getting slower and it was getting more difficult by the year to compete in the open division. As I approached age 39, I read that the National Masters XC champ would be returning to Boston but that the open division race would now be held at a separate time and location. This didn't bother me because I would be a master. I slowly started “ramping” up training. There was a lot of grass running leading to repeat miles on a boring, flat, devoid of shade course I laid out around the outside of the track on the school grounds. This was the best I could do in park-bare Weymouth to get a necessary pillar of cross country training. One can transition from grass to roads but you cannot go from road training and expect to do well on grass. I trained through a 5k developmental XC race to get the first feel of running in spikes since college. Then after a couple of weeks where many of my repeat miles dipped under 5 minutes per mile, I ran the New England XC champs. I finished 3rd, just barely loosing out in a last minute battle for second with Jack Fultz (two time winner of the Boston Marathon). Then, I fully backed off on the training and did my goal race. I was 7th in the Nationals and exacted my revenge on Fultz, who finished a couple of places back.

So, my goal was complete.....or so I thought until the invitation to the Worlds came in the mail. USA was the host country for the first time in 20 or 30 years and Buffalo was the host city. Hmmmmm. Doable! Very Doable. The race would be July 12 which was at the end of my hard to change, already scheduled vacation. The wife and son did not want to give up our Nova Scotia trip so the compromise was a slightly shortened Nova Scotia trip, then shuffle off to Buffalo. My first thoughts when opening the invitation: July 12th in upstate New York.......it will probably be 90 degrees and humid. So bring on the encore presentation of repeat grass miles and Sunday fartlek workouts. Add some weight lifting type workouts to boot. Then resist the urge to remove that extra clothing layer in the spring all the way into the summer. By the time we transition into summer, I'm still doing my workouts when it is 80 degrees with a rain suit on. This culminates in my last full length workout 5 days before the big race. I ran an easy paced 11 miles on a 90 degree day in a full rain suit. Since 90 days are rare in Aylesford, Nova Scotia and most locals were suffering in the heat, I was quite a sight to the locals in my heavy running gear.

Sunday- There is heavy bumper to bumper traffic through Maine that afternoon. We decide to drive an extra 50 miles and sleep at home in our own beds in Massachusetts.

Monday- Then, go west, young (errr old) man. We make it as far as Syracuse and stay in a motel. Tuesday- Next morning I wake up and I cannot put any weight on my left leg. It is two days before race day. First thought, panic! The next thought: okay, what did I do that was unusual 1-2 days ago? Ah, heavy clutch activity in our standard transmission car in Maine. I hobble out to the car and continue a gimpy shuffle off to Buffalo.

Wednesday- I wake up in Buffalo and the leg has made quite a recovery. A short run confirms my opinion. I go to a team meeting /athlete orientation. WAVA (World Amateur Veterans Association- the arm of IAAF that handles us geezers) and IAAF(the organization that runs the Olympics) officials “lay down the law” about conduct, random drug testing, etc. I rest in the motel for the afternoon and watch my son. My wife goes and tours around Niagra Falls.

Thursday- It's race day! Out to Akron Falls, the site of the cross-country venue. We reserve a spot in a campground only a couple of miles away for afterwards, then off to the race. I was wrong about the knee jerk temperature prediction. It wasn't 90 and humid. It was 99 and humid! My race was last as they started with the older age groups of both men and women. Half hour before race time, warming up. The course is 10,000 meters (6.21 miles), has a lot of up hill in the first half (my forte) and is flat or downhill in the second half. The last mile culminates in a lot of downhill (my weakness). 10 minutes before race time, there is an announcement. 24 people treated by medics on the scene today and 10 of those requiring hospitalization. The event has been postponed until further notice. Shock and disbelief set in. A meeting was scheduled at the Games headquarters tomorrow. It was only announced in English. A Runner from Portugal standing next to me is lost in concept due to the language gap. I don't know the language but I do know a little Spanish. I successfully get the concept across in the third party language. Back to the campground. We see groups of teens heading into the campground with cases of beer, possible impending bad weather, and a race possibly still to be run. There are broken beer bottles on our tent site. We decide to leave. Buffalo is out of the question for accommodations with the Worlds now in full swing. Severe weather alerts are starting to come across the radio. We pull into a motel in Akron Falls. I forget the name. I think it was the Bates Motel or something like that (psycho violins sound effects scream in the background). The manager, who has a strange resemblance to a young Anthony Hopkins shows us to a room. My 5 year old son goes to sit on the bed and it collapses <>psycho violins. Mr. Hopkins shows us another room and the bed is fine. We take it. Later, I check the bathroom and see an old porcelain tub style shower with a white vinyl shower curtain. The light in the shower is a bare bulb hanging from two wires. There is no cover plate protecting the electrical outlet. <>more shrieking violins Now there are violent thunderstorm warnings and a tornado warning for this area. I have the urge to shut the TV off for fear of a Hitchcock film festival being the feature presentation.

Friday (the 13th )- Well, we made it through the night. No conversations with a long dead mother or daggers in the dark. It's off to a meeting that hopefully will not be run by a fellow in a hockey mask named Jason. An official looking person comes in and reads a brief statement. The gist is that the race will be run Monday morning at 9:00. This looks grim for me. My wife must be back to work Monday and Horror Hotel is out of the question for even another night. I see the Portuguese runner I met yesterday and tell him that it is unlikely that I will be able to run. He tells me in Spanish, “Hay uno o dos cuartos vacíos en mi edificio en la aldea del atleta (There are one or two empty rooms in my building in the Athlete village).” This is confirmed with a WAVA official so the wheels of Instride's scheming gears start to turn. My wife and son head home. I stay and eat in the Athlete village and take a flight from Buffalo to Boston. I miss my scheduled work in a nursing home on Monday, but they were already in the process of giving my work to a multi-health service corporation. So a delay till the following weekend shouldn't ruffle any feathers. So it's settled. I continue the quest. Take that, Jason!

I was on the tenth floor of a building without air conditioning. The only people who spoke English on my floor were those from New Zealand and they generally kept to themselves. I wasn't going to go to Opening ceremonies tonight (sounded too pomp and circumstance for me) but changed my mind to get some human contact after many hours of solitude. It was clearly my best decision of this adventure. I had never experienced the full roar of tens of thousands of people cheering on the home team when we entered the stadium in our USA uniforms. I was placed in the front row for the procession because someone decided I looked good in my uniform (somebody better give that official a drug test). There were fireworks, Elvis impersonators parachuting to a target on the 50 yard line, a Chubby Checkers concert, acrobats and dancers. All in all, it was quite entertaining. Ingrained in my mind was that Ruth Anderson as the torch person to light the “Olympic flame.” She dropped the torch after lighting the flame and the flammable material from the torch must have spilled and caught fire. The platform was engulfed in flames but a quick acting fire fighter whisked her out of there with only suffering minor burns rather than doing a Joan of Arc imitation.

Saturday- It is still hotter than Hingham House of Pizza Buffalo wings. Rod Dixon wins the 800 meters in that furnace. I remembered him medalling at the Montreal Olympics in the black uniform of New Zealand.

My travels lead me to discover an air conditioned room in a place housing mostly Australian athletes. The “cool room” was one of the few comfortable places around. They quickly adopt me as one of their own on the basis of his wit and story telling. One of the Aussie women I spoke with makes it through the prelims and semis in the 100 meters. Her physical rehab between races is thorough and her demeanor is incredibly focused. I now have some new found respect for sprinters. I told her that maybe I'll watch her race Sunday night to offer moral support. She says if I do anything other than rest for my race, she would personally beat me up. Considering the size of here biceps and the speed in her legs, I have no doubt that she could keep her word. I followed her advice.

Sunday- I don't know if it is hot enough to fry an egg or humid enough to poach that egg. Maybe I could tell if I could figure out which came first, the roasted chicken or these hard boiled attempts at wit.

It's tough getting to bed. The heat is bad but the temperature in my subconscious is starting to rise. I'm starting to doubt whether I belong in this caliper of competition. I wake up in the middle of the night. I head out to the John. An empty bladder makes for better sleep. I notice that I'm rubbing elbows with Rod Dixon who is draining his dragon in the adjacent urinal. If piss and vinegar count, maybe I do belong here.

Monday- Race day for real! I make my way to a shuttle bus at some ungodly hour for a nearly one hour ride. Even though it was early, the weather was more reminiscent of fire and brimstone than a heavenly dream. We line up on a course that starts right up a hill. Bang! The gun goes off 4 days late and a whole bunch of dollars short. Feeling the adrenalin and a gift of good hill climbing, I'm in the lead pack as the hill levels and then transforms into a gradual downhill. I ease into a rhythm as others up their tempo. People pass me by in droves. The situation reminded me of that childhood nightmare where you are trying to run away from something or someone and going in slow motion. It seemed like everyone in the race must have passed me by the mile mark. I was waiting for the Laugh-In man in a yellow raincoat on a tricycle to come scooting by. Still, this is no time to panic. There are many uphill sections over the next two miles for me to use my strength. I gain on no one over the next mile and a half. On the most challenging uphill on the course at about 2.5 miles, I catch no one. Someone even goes by me. Maybe it is time to panic. However, the little over-achiever voice in my head says I'm out here to do my best.....to represent myself, my team, and my country. Have pride and do your best. I retrench and refocus on my race effort, whatever that may turn out to be. Then, a funny thing happened after we hit the halfway mark. The course opened up onto a huge grassy field. It reminded me of the conditions where I did my repeat miles: flat, groomed grass, and hotter than blazes! The tide turned. I started passing people. Only one person went by me in the next 2 miles. He said something in an Eastern European language. I could not understand the words but the tone of his voice was encouraging. He could have been saying that my mother eats kitty litter and I wouldn't have known it. I tend to lean towards kind words because of the tone. Ah! I know. He must have said, “Slovac and steady wins the race.” Well, so much for oxygen debt humor. I start the downhill last mile and I'm still getting by competitors. I pass three more in the final 200 meters. I didn't have the slightest idea as to my place in the race. I was just happy that I gave my all and had done my best on this given day. The race was won by Grenville Wood of Australia. I hope he is as nice as the Aussies who shared their cool room with me. Joaquim Pereira was second, and Francisco Ribiero took the bronze (both from Portugal). The slots started to fill in on a top ten board. Then low and behold, the tenth slot is filled and says Robert Chasen USA. A wry but satisfying smile came to my face. Dream-Mission Impossible is accomplished. Then, as they say on a Ronco commercial, “wait there's more...” The team scores were then posted and the USA won the silver medal (Portugal won the gold).

It may be a team medal I was awarded. However, no piece of hardware on my awards shelf has such a rich individual story to tell. Yes, all that glitters isn't always gold. Sometimes it is the silver lining to a dream fulfilled.

Breaking the tape

2008-09-24T16:56:00.000-07:00

I have been asked too many times over the last month about the tape Olympic beach volleyball athletes, Kerri Walsh and Misty May-Treanor wore during the Beijing Olympics. Does it do anything or is it a promotional gimmick?

I cannot answer whether money changed hands. Only their manager and hairdresser know for sure. However, I can tell you this. The tape on their legs and shoulders is a useful tool in the arsenal on the war against injuries. It is a Japanese product called Kinesio Tex® Tape. It is a very thin (about the same thickness as skin), porous cotton fabric with a medical grade acrylic adhesive. A special method of adhesive application and porous nature of the fabric allows the skin to breathe and showering cleans part of the skin under the tape. The tape is designed for a 30 to 40% longitudinal only stretch and when applied lifts the skin and provides support for surrounding soft tissue. This support occurs by reducing the eccentric muscle firing needed to decelerate the muscle group forces it is taped over yet allowing the athlete to still function in his or her sport. I use this tape in my office myself for certain types of injuries (usually those with eccentric overload causes).
So is it marketing? Maybe. The Olympics is big business and who wouldn’t want product with bikini clad healthy women. Is it useful? Definitely

Plantar Fasciitis

2008-08-14T16:15:00.000-07:00

Plantar Fasciitis is an injury caused by excessive stretching of a broad band of fibrous tissue which runs along the bottom surface of the foot, attaching at the bottom of the heel bone and extending to the forefoot. The band stores energy from heel contact in a windlass mechanism and returns most of it to push the foot off the ground. The term is often used to include the layer of muscles which adhere to it. A chronic plantar fasciitis eventually becomes a heel spur in most cases. My treatment will typically begin by determining and addressing the cause or causes of the injury. No injury can have a set cookie cutter treatment. Each patient's treatment plan varies according to the contributing causes.

The common causes and aggravating factors are:

Over-pronation (flat feet)

But also a foot with a high arch

A sudden increase in length and intensity of workouts

Excessive weight change

Pregnancy

Improperly fitting footwear

Tightness of the foot and calf (gastocnemius and solues are most common culprits)

Training errors

Old running shoes

Improperly fitting running shoes (especially too wide)

Improperly designed running shoes

Rheumatoid variant types of arthritis (HLAB27 antigen positive) and disorders of connective tissue healing

Running on surfaces too soft

fixated or subluxation at calcaneal cuboid and talo-crural joints

The use of medical grade silicone gel heel cushions, and compression socks used as first aid is as close as I come to a universal thing to do. This is rarely curative but is meant to reduce symptoms . Some people like to tape the foot. This is okay for short time intervals as a taping lasts 3-5 days. Socks with spandex woven into them when the need is likely to be more long term. Nonsteroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen, etc.) have significant benefits only in arthritis induced cases. Arthitis induced cases are rare. Most cases of plantar fasciitis lack inflammation. Hence, such drugs often misused for this condition. Deep tissue massage is helpful in some cases. Night splints (which immobilize the ankle during sleep) are well hyped. They have been used with mixed results, at best over the last decade. Stretching and strengthening programs are good for those people who have a tightness of a weakness. Orthotic devices are considered only for those people with a biomechanical fault. A Cortisone injection into the scarred attachment has a success rate of about 50%. Healing modulators, such as injectable preparations containing Arnica Montana have been shown to speed the healing course. Manual mobilization of the calcaneal-cuboid and/or talo-crural joint help those people with subluxations or fixations. The final option, surgery to release the tight fascial bands has a 70-90% success rate. Shockwave therapy fits is as an alternative to surgery. Shockwave or more formally known as Extracorporeal Shockwave Treatment is a relatively new delivery of high energy sound waves to affected areas of the body. It is very similar to the units used in certain cases to brake up kidney stones. It works theoretically by creating controlled injury of the plantar fascia insertion. Proponents are claiming to have success similar to percutaneaous (small incision) surgery. It requires anesthesia and has a timetable similar to small incision surgery. Shockwave theapy is contraindicated in people with diabetes, concurrent nerve-related problems, vascular, pregnancy, clotting disorders (or taking any drug which thins the blood) or various types of arthritis.The present studies I have read on the effectiveness of this therapy are mixed and controversial. Because of this, it is not covered by many insurance companies. The positive studies so far have all been funded by companies who make the unit. I would like to see one by a source with no vested interest before I start to forge my own opinion of the therapy. Only time will tell how good this alternative will be. You have heard the phrase "time heals all wounds? Well time also wounds all heels.

There are also other treatments used in plantar fasciitis by me in cases of an atypical cause of the problem. For example, I remember one athlete on a college scholarship who had seen just about every sports medicine doctor in the Boston area. Both the athlete and her coach were very frustrated after over 3 years of inability to run. The only thing I could find was a wart on the ball of her foot. A wart does not hurt with direct pressure but it usually very painful with side to side pressure. To make a long story short, I removed the lesion and all pain went miraculously away. Not all heel pain is plantar fasciitis. Spinal impingement (at the 5th lumbar or 1st sacral vertebra), tarsal tunnel syndrome, nerve entrapment, Sever's Disease (calcaneal apophysitis), bone cysts and benign tumors can all mimic plantar fasciitis symptoms.

Hopefully this information will enlighten readers of this blog about their McFeet. For we all need help from the sign of the golden arches one time or another.

Tapestry

2008-08-10T06:05:00.000-07:00

I lie curled up on a cot, shivering under a military blanket. I started to cry first as a whimper. But as the dam gave way, the trickle became a deluge. An EMT came over to quickly access the situation, “anything wrong? Are you in pain?” I turned and replied, “No it is just the pain going away.” A perplexed worker stood and stared, then finally walked away. Had I lost my sanity? Here is my story. It was a full blown New England Nor'easter as I waited inside the school for the start of the Ocean State Marathon. Huge thunder claps reverberated the room and lightning flashed in the gym skylights as I stretched on the floor. I overheard a passer-by say, “It sounds like a hogs heaven rally in the air going on out there.”

I said I would run another marathon when pigs fly. That was 1982 in the Foxboro Marathon. I was invited as the guest lecturer for their sport medicine seminar the night before. Running the race would be a good follow through for me. I prepared with long runs and a variety quality workouts. I trained and planned to be prepared. But somehow, even the best plans of mice and men can go awry. That is especially so at about the 21 mile mark when glycogen supplies of the muscles have a tendency to ebb. My brisk pace slowed to what seemed like a crawl. Less than 100 yards from the finish both hamstrings seized up. You've seen it before on the news. A runner doing an imitation of a telephone pole right before the finish. No matter how I tried to take even the smallest of baby steps, my legs would paralyze in spasm. I had come this far. The cameras, finish line spectators, and the clock were in front of me, creating a surreal nightmare. I reached down for something physical and nothing was there. When the flesh is weak, it is time to explore the spirit. I searched the recesses of my mind for an answer. An image then appears of my cat who loved to play with me by challenging me to catch her. She did so by staring me down while making her eyes look big and round, arching her back, escaping me while running backward. I never caught her. If I got too close, she would give a four legged leap 6 to 7 feet in the air all the while twisting and gyrating in ways that would make a gymnast jealous. Okay, idea strikes. If the hamstrings are out to lunch, why not pivot myself around and go backward to use the quads instead. Sure enough, I could move a little. I finished walking slowly backwards, much to the delight of spectators and film crews.

The loudspeaker breaks my reflections, “10 minutes till the start of the race. Please make your way to the starting line. Make sure your number and team tag if you are on one is on the front of your jersey.”

My team was one man short for scoring in this grand prix championship event. I had dedicated my performances in the grand prix to my cat, Windy, who lost her battle with cancer several months earlier. Some people are musicians and can write a song. Others are artists and paint or sculpt a masterpiece. I only have a reasonably fast pair of legs to define who I am. I raced wearing a tea shirt bearing her picture. I had run superbly in those earlier races but figured I would end my season before the marathon. Here was my chance to put an exclamation point on that tribute.

“We'd like to give tribute to the Mayor of West Warwick...” the starters bullhorn droned on. The rain, thunder and lightning had ceased. The weather was finally starting to cooperate as they ended the V.I.P. introductions.

Our introduction was awkward at best. This cream and blue calico cat came out of a side alley begging for food. She was a full grown cat that was emaciated down to just 4 pounds. My wife asked someone on the porch of a nearby apartment if she knew who the cat belonged to. The person replied that the cat was one of many strays that fend for themselves in the alley behind the building. Faster than you spell hooked, she brought the cat home to our no pets allowed apartment and raided our $10 a week food supply for something a cat would eat. I not only lost part of my week's sustenance, but she came right in and ate a spider in the corner of the apartment. I coexisted with this arachnid because it worked better than any can of poison to get rid of biting red ants in the apartment. Now I have a type of animal I never have had any previous contact with eating my precious few morsels of food returning me to a life of ant bites. The cat just stood there and blinked here eyes at me.

I blinked into a stray droplet of rain as the starters gun fired and the race went off. I settled into a comfortable 5:55 pace for the first two miles. Then the course takes a left turn once you reach the Atlantic coast to head northeast for the next 23 miles or so. This normally would not be a problem, except the start weather was just a lull in a powerful Nor'easter. A Nor'easter is October to April precipitation event named for the winds that blow in from the northeast and drive the storm up the east coast along the Gulf Stream. This a band of warm water that lies off the Atlantic coast fuels the storm to make it even more powerful. The winds took any spunk right out of your stride. I worked extra hard to catch up to 3 runners running side by side about 100 yards ahead. Even with the extra effort the pace slowed to 6:10 for the next mile. I already know that the marathon is a long and humbling race. It was time to tuck in behind them and “dog it” for awhile.

I was in a small park near my apartment with Windy on a warm spring day. She enjoyed the outdoors but we tried to do it in a supervised fashion. Suddenly a huge unleashed German Shepherd had her cornered. I rushed into the fray and quickly swooped here up. Windy immediately became calm once in my arms. “You mean she didn't claw you trying to get away,” my wife said, “I never heard of a cat doing that. There's some kind of a special bond between you two.” Windy always considered my lap a safe place to be.

I stayed with that group as if their was a rope around my lap attached to them. Two of them fell off the pace at 9 miles. The other runner took off ahead of me at 10 miles as we passed through in 61:20. I was happy to keep pace and let him go. The rain was really starting to intensify, again. The wind didn't seem quite as bad but still had a bite to it.

I was on the porch of our apartment in Massachusetts. Another cat came across the lawn and became friendly with me. Windy she sat on the other side of me while I pet the cat. She scrunched her eyelids in an disapproving manner. Suddenly the cat bit me on the hand for no apparent reason. Windy growled and leaped over me chasing the cat right off the property. She stopped at the property line whipping her tail back and forth staring down this fleeing feline.

The rain was starting to pick back up as I passed that same runner between mile 14 and 15. At about mile 17 there was a stream coming down a street across my path. It feels more like a steeplechase rather than a marathon. Someone once said that I was so thin that I could run around in a shower and not get wet. However this was no ordinary rain. By mile 18, I was so cold and drenched that I was numb below mid calf on both feet. It was a very strange sensation when running, indeed. At least my feet did not hurt.

There was a wet matted area on the fur of her neck. I found this to be odd for an immaculately clean cat. I brought her in for her 5 month overdue annual check-up. The veternarian found a growth on the underside of her tongue and thought the possible diagnosis was bad. I had him perform an excisional biopsy. The diagnosis was squamous cell carcinoma, an extremely aggressive and deadly cancer in cats. Windy was unusually good for a cat. She took all the pills I gave here without much fuss and even let me give her subcutaneous fluids with a needle to take the stress off of her now straining kidneys. She would give me adoring soulful eye contact even after this painful treatment. It was as if you understood the whole situation.

I hit the 20 mile mark in 2:01:40. I became leery of the dreaded marathon wall that was the start of my undoing 15 years ago.

Sometimes I wondered how she escaped my room to greet patients in my office attached to my home. Then one day I had her in the room with me while I was resting in bed with the flu. I heard a sound and rolled over in bed to see Windy on a chair next to the door. She was “standing” on her hind legs using her two front paws to jiggle the door knob. The door opened and out she went.

Instead I felt better than I had all race. It was as if someone had opened a door in the marathon wall. I picked up my effort through a small village. I felt invincible but knew better than to keep the hammer that far down as the legs started to fatigue at about mile 24.

One day early in June, she felt well enough to issue me the arched back catch me if you can game. I caught her for the first time ever. Rather than gloat about my victory, I fell into a tearful embrace of her. She in turn, looked at me and rubbed her cheek onto side of my face.

Shortly thereafter, we turned out of the wind, but the slowly mounting fatigue made the loss of the wind handicap, unnoticeable. The flooding roads were camouflaging potholes in the road construction as the rain continued to fall. I stepped into one of those potholes with my right foot. It was about 2 feet deep. I went down onto the flooded road face first.

I had a lousy Father's Day. First I was lead off course while running what would have been a nationally ranked masters 10K time. Then I come home to the real bomb. For the first time, Windy won't let me give her the daily medications. At the local animal hospital, they take some tests. The advancing cancer had ulcerated right through the lining of her mouth and could not be repaired. This was causing massive infection which could be controlled by antibiotics but not stopped. The cancer had also spread to hear lungs. I should have known something was up. Usually she sleeps on or next to my legs. That morning, I woke to her on my chest with both front paws in full embrace of my neck. Windy took the journey to the rainbow bridge that following Monday morning. She sat on my lap, the safe place, as the series of three injections were administered to finish the lethal process. It was the most difficult thing I have ever had to do.

Picking myself up out of a 2 foot pot hole in a storm during a marathon was a small hurdle on the steeplechase course of life after black Monday. I got up and made my way up to the finish line. The clock said 2:42 as this weary 43 year old body crossed the line a full 17 or 18 minutes behind the young Kenyan winner. It was not a day for times and records. It was a day for courage and commitments. That was fine by me for I had kept mine to a special fury friend.

The EMT tried to take my wet shirt away from me. “No!” I yelled, “it's source of warmth as I clutched it even closer to me. He completely gave up to attending me after that. But, the pain was leaving and the shirt with her image was warm. The sampling of the memories I have shared of here are tightly woven into my adventures like a strong but beautiful tapestry. Such fabrics resist the fraying stresses that life brings along its journey.