THE CLINIC
Staring Down a Surgical Three-peat
I am a 140-lb, 5' 10" male and I have had two arthroscopic knee surgeries to resolve a torn meniscus and frayed cartilage and bone chips resulting from a fall five years ago. The first surgery entailed drilling a hole in my femur to help blood supply rebuild the damage to my knee. I was consequently on one knee for more than eight weeks and suffered overuse injury to that knee. I racewalk, bike, and rollerblade currently, having been told never to run again. I have been diagnosed with a shifted kneecap in the originally injured knee, and my orthopedic surgeon wants to do major surgery to repair it. Is this really necessary? I have read a lot about similar problems being corrected through exercise. I should add that there is evidence of osteoarthritis as a result of the injury and my age (52). I have been a runner only since I was 24 and wonder is it really the case that I may never run again? Also, is surgery the only answer for the current patella abnormality?
David Dunst
Hollywood, FL
Keep in mind that racewalking and biking are also notorious for producing patellofemoral pain. If you go for the surgery, your recovery time would be one year to 18 months. A proper flexibility program can often result in avoiding surgery. To a large extent this depends on the amount of space left between your kneecap and femur. This is called a "sunrise view" x-ray. It's also useful to determine via x-ray criteria how severe your osteoarthritis is. There is a continuum from mild to severe. Surgery will not improve your ability to run, and even after a year and a half recovery it is important to use a cushioned shoe with orthotics and start on grass only. Most patellofemoral problems are caused by a tightness or contracture in the thigh muscle and iliotibial band. I have had seen senior runners who have taken tai chi or yoga and over about six months increased their flexibility to the point where they were pain free and running.
Robert C. Erickson, MD
Canton, OH
There are a few problems here working in tandem that are hard to deal with and present a challenge for any orthopedist: a sprinter with hamstring tears, and a distance runner with wear and tear changes to not one knee but both now.
I recommend a second opinion, if you have not already sought this out, and then perhaps even additional opinions. In general, we try to avoid surgery until there is no other solution. Knee rehab exercises should be used seriously for three to six months before considering a surgical solution. I would look at whether a new MRI might be helpful here. Patella tracking problems can be nasty and take considerable experience on the part of the physician and surgeon. Try the use of a patella centering brace, and also strengthen your quadriceps before you try anything else. It is possible you will run again, but I would not expect the cure to be easy. Try to make maximal use of crosstraining, and always remember that there is life after running and joy to be found in a variety of activities.
Larry Hull, MD
Centralia, WA
Is My Fatigue Definitely Heart-Related?
I take a beta blocker to control my blood pressure, and have been for the past 20 years. I am in my late 70s and run marathons without any health problems. I typically finish strong on my 10- to 15-mile long runs. I log about 35 miles a week, and crosstrain on a bike. About six months ago I began feeling tired and winded more easily while running. After an echocardiogram, I was diagnosed with leaky heart valves. My physician has advised me not to run more than three miles at a time. I am currently training for several upcoming competitive events. I don't want to place my health in jeopardy, but surely there must be a way to continue to train at a higher level than my physician has prescribed. What can I do?
Jan Cordova
Kent, MO
Without knowing more details about your medical history, I can only make general comments I hope will be useful. The symptoms you describe—earlier fatigue and increased shortness of breath—are nonspecific; there are a number of entities that can account for these symptoms. The first step is to make sure the symptoms are due to the leaky heart valves, and not some other entity. The echocardiogram is extremely sensitive for detecting trivial or mild degrees of leakage that may be of no clinical significance. For instance, approximately 50% of people with otherwise normal hearts and no clinical evidence of valve leakage will have trivial or mild aortic or mitral regurgitation (these are the two valves on the left side of the heart).
It's important to know which valves have leakage and the degree of leakage. Grading the degree of leakage is a somewhat subjective process. It's therefore important that the echo tape be reviewed by someone with extensive experience in valvular heart disease. In some people, the severity of the leakage may be more accurately assessed by a transesophageal echocardiogram, which requires passing a probe down the throat. (The more routine procedure is a transthoracic echocardiogram.)
If you only have mild to moderate regurgitation of the aortic and/or mitral valve, you should be able to continue participating in competitive events, assuming your symptoms do not otherwise limit you. However, if you have moderate to severe regurgitation, you might benefit from additional treatments, one of which could include surgery to replace or repair the leaky valve. I feel that this type of surgery should only be performed in a medical center that has extensive experience with these types of operations.
Todd Miller, MD
Rochester, MN
What's Causing These Cramps?
I've run nine marathons and five half-marathons. Last March I experienced calf cramps that made it impossible to run, though I was able to walk. The cramps hit me at 20 miles. This February at another marathon the calf cramps hit me at 17 miles; I was able to walk the other nine miles. A month later the cramps started at the finish of the local
malf-marathon. Both marathons were very warm, in the 80- to 90-degree range. I was well-hydrated, however, especially in the second marathon. I am a 48-year-old female running 25 to 30 miles per week and have been in perimenopause for two to three years. Calf cramps never hit me until she recently. Any ideas? What do you think of performing blood tests for minerals or electrolytes?
Lacy McGill
Franklin, LA
I feel there are several things that may be causing your cramps. Perhaps you are having electrolyte difficulties but I am not so sure that this is the real issue. Being perimenopausal could be contributing to this but I am not familiar with a specific link between the two.
More likely, the cause is muscle fatigue for one of two reasons, or even both. First, in slower runners there is a tendency to overload the calf muscles eccentrically (while your foot is planted and you are moving your body over your foot). This causes the fatigue, and cramp. Second, if you have any compression of nerve roots from your back you may be reducing the available power supply to your legs and causing the fatigue to happen sooner than it normally would. Compression would happen in people with a disc
protrusion (new or old), spinal arthritis, or both. Do you have any history of back problems? Even if if you don't, sometimes this phenomenon can be silent as far as the back is concerned. Because running is a high-demand activity, the problem may be mild enough that it only shows up when there is high demand placed on the nerve.
I suggest you see a sports medicine physician who is knowledgeable about the problem I outlined above. You might also check in with physicians in your area familiar with athletes who cramp due to excessive sweating and electrolyte loss.
John Cianca, MD
Houston, TX
Cramps can happen for a number of reasons, including dehydration, over-hydration, electrolyte abnormalities, and muscle fatigue. You didn't mention any problems on long training runs so we need to look at what is different on race day. If you are running at a faster pace than on training runs, fatigue is a problem. You should perform runs at your planned marathon pace during training; too often, pace is faster than this on short
runs and slower on long runs. Gradually increase runs at marathon pace from 8 miles to 15 miles.
Sweat rates are variable from person to person and will change with acclimatization and weather conditions. It is hot and humid in your region of the country, so weigh in without clothes prior to a long run and again following the run. Each pound lost is a 16-oz fluid deficit; you need to add the amount of fluid that you consumed during the run to this to estimate sweat rate. Repeating this in various weather conditions can provide a good range in sweat rate. A runner who is a little under- or over-hydrated should not experience problems. It is possible to consume too much fluid while running, causing
blood sodium levels to drop. This can cause swelling, cramping, nausea, vomiting, seizures, and worse. Salty snacks or supplements may help prevent this, but avoiding over-hydration is the key factor.
The fact that you can continue walking without a problem after cramping starts leads me to believe that fatigue may be the more significant factor. Incorporating strength training may also be helpful. To work on calf strength, raises should be performed at the edge of a step, dropping the heels down below the step and then rising onto your toes.
Cathy Fieseler, MD
Tyler, TX
Leg Pain on Days off from Running
The pain in my left hamstring has become chronic. This is new for me; I've been running for years and have never had problems before. I am very careful to only increase mileage gradually. Right now, in fact, I'm running just three times a week, for a total of 20 to 30 miles.
The pain started when I was training for a marathon, even though I was following a very conservative run-walk program. It has been ongoing for several months. I was originally diagnosed with hamstring tendonitis. I quit running for about three weeks and went through several weeks of physical therapy, but the pain would resume almost immediately. Nothing showed up on an MRI of my left leg.
I have difficulty believing I have tendonitis. The pain is often most noticeable on days when I'm not running. Now I've begun to have tailbone pain, particularly after running. My regular physician gave me a basic exam and some anti-inflammatories for this. I'm a bit at a loss as to who to see next—another orthopedist, or perhaps a chiropractor? I really would like to get to the bottom of this problem, and not suffer through more trial and error.
George Evanoski
Fairfax, VA
It sounds like you may need an MRI of your lower back, not your left leg. Often a lower back or sciatic issue will yield symptoms like this, including the hamstring pain manifesting after inactivity, and of course the recent tailbone pain. Anti-inflammatories address the symptom, not the problem.
I would strongly consider a lower back flexibility program, over about three months before you look for results. It may take six months to work. Once you feel better, continue treating your back or the condition will return in as little as six weeks. The simplest program is to sit on the edge of a chair and bend your head down between your legs. Do this for 10 seconds, five to six times a day. Another option is to purchase a lumbar elastic belt with dual Velcro adjustments for about $24. Try running in it and see if the pain is slightly less. Just be wary of overtightening or you won't be able to breathe properly. A sports therapist can give you a comprehensive lower back stretching program, during a session in which the doctor coaches you on exercise form and gives you things you can do at home.
Robert C. Erickson, MD
Canton, OH
I see the type of injury you have frequently and treatment can be elusive if you just focus on the symptoms. The cause is probably not your hamstring, but how you run and the cumulative effects of that gait pattern. This is ultimately the source of the overload, and the ensuing symptoms. You may, for example, have pelvic dysfunction. I also can't rule out lumbar pathology as a source for your thigh pain. You may have tendonitis but the treatment must be directed at treating the reason the tendonitis arose, and not just the symptoms that declare themselves. If the muscles of your pelvis and trunk are not working well enough to stabilize your pelvis during running, your hamstring or adductors may become overloaded as they try to keep you upright and moving somewhat efficiently.
You should probably see a physical medicine specialist with a mind toward function. I think you could benefit from a gait analysis and a musculoskeletal exam. In the meantime, work on hip abductor (gluteus medius) strength. Using a cable column, stand on one leg and pull the cable away from your side with the other leg from the ankle. Repeat on the other side. Do side-lying leg lifts, as well as squats with your buttocks back and loaded as if you were going to sit down. Also, reduce your running to an amount you can tolerate.
John Cianca, MD
Houston, TX |
