Ask Dr Bob (#3)

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

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

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

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

(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

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

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.