The following essays are extracts of monthly articles written for the Syracuse Track Club newsletter by Dr. Dan Wnorowski.
Click on a topic below.
Before you call the doctor…
Consider this scenario, a runner with persistent pain that came on gradually, “That nagging pain keeps getting worse. It is getting difficult to forget about it during my runs now, and after my runs the pain persists. Maybe there’s some swelling. This is no longer fun. I wonder if I’ll be able to make that race. It’s certainly going to be tough to make that PR. Should I make an appointment?”
Don’t panic. Think rationally about your injury, your problem. What have you done to provoke this? Where is the pain? What makes it worse? What makes it better? What has changed in your training regimen; more mileage, new route, hills, surface, speed work? Have you been running without stretching? Is it those new shoes? Have you had this problem before?
What have you done to promote healing of your injury? Have you given your body a chance to heal itself? Have you adjusted your training program, tried cross training, changed your route or intensity, reduced your mileage? Have you tried icing, stretching, or over-the-counter anti-inflammatory medications? How is your diet? Are you getting enough sleep?
What about the usual first-aid measures? Although the “best” healing will occur under the condition of absolute rest, this is not always practical, or even possible. The next best thing is relative rest. This means decreasing exercise duration or intensity, or substituting complementary activities, e.g.- low-impact swimming or cycling for running when recovering from shin splints. The goal is to maintain aerobic fitness while allowing healing of the injury, under conditions of diminished stress.
All running injuries are accompanied by inflammation. Injury to living tissue causes damage and death to cells, life’s basic building blocks. When cells die, enzymes are released that trigger the inflammatory process. The cardinal symptoms and signs of inflammation are pain, swelling, redness, and warmth (Latin: dolor, tumor, rubor, and calor, respectively). Although inflammation is the first stage of healing, suppression of inflammation also facilitates rehabilitation and ongoing function. Inflammation is inhibited by ice, wraps, elevation, and anti-inflammatory medication (aspirin, ibuprofen, naproxen, etc.; acetominophen is not an anti-inflammatory). Inflamed tissues tend to be tight, because of the swelling and healing scar tissue, hence the need for religious stretching when trying to get over the hump.
Finally, consider biomechanics. For example, the pronated foot (flat-foot), contributes to many types of injuries that may manifest as foot, leg, or knee pain. A change in footware may lead to a change in arch support, alteration in foot alignment, and biomechanical alterations on up the “kinetic chain” of the leg.
If you have thought about and perhaps tried some or all of these things, and you see no progress, then perhaps it is time to consult a professional. It would be wise to think about these topics before your appointment, or at least while you’re waiting for the doctor. A good medical history for the injured runner will include questions and conversation about all of the above, so be well-prepared, and bring your favorite shoes and shorts. Happy and healthy running!
Dan Wnorowski, M.D.
Running and Arthritis- Cartilage Supplements
Last month I reviewed some recent literature regarding running and arthritis. Some of the hottest selling items in pharmacies and health food stores are glucosamine and chondroitin sulfate. These are dietary supplements that are touted as “chondroprotective and chondrorestorative”. This means that they may assist in the protection and repair of damaged joint cartilage. “Chondro-” means cartilage.
The gliding and sliding surfaces of the bones that make up the joints are composed of cartilage. Cartilage is a soft and pliable, but resilient living tissue that is like teflon. Cartilage is unique in that it is a highly specialized material that is highly permeable, with extremely low friction. Although there are many living cells in cartilage, called chondrocytes, there are virtually no blood vessels, so these cells get nourishment from diffusion. The living cells are immersed as islands of life within the cartilage substrate that they have manufactured and extruded in the past. This substrate is like a bridge road surface. There are long strands of “rebar” like filaments woven amongst a sea of rubbery-plastic-like cement. It is as if the cement-mixers that have poured the cement are stuck within their product. Because of this architecture, highly specialized biology, and the lack of a blood supply, traditional thought is that cartilage tissue has minimal, if any, capacity for repair.
As orthopedic surgeons, we are trained to consider that cartilage tissue has NO INHERENT HEALING CAPACITY, unless the cartilage layer is worn or injured down to the underlying bone, where the blood vessels are located. Conventional and operative procedures have been designed to generate access to the blood supply, and thus encourage healing by stimulation of reparative fibrocartilage, and different type of “scar cartilage”.
Proponents of chondroitin and glucosamine nutritional supplements argue that these natural cartilage building blocks not only help preserve this vital tissue, but also help heal and restore joint cartilage. Claims by the producers of these elements include: stimulation of the synthesis of cartilage cells and joint lubricant (hyaluronic acid), inhibition of damaging enzymes, enhancement of the blood supply of the joint tissue, and decrease in joint pain and inflammation. Conventional medical treatment such as acetominophen and anti-inflammatory drugs certainly cannot do all of these things.
Studies based upon subjective reports of arthritic users, mostly from Europe and Asia, have shown good pain relief and increased comfort after use of these supplements. They are heavily marketed as anti-arthritic agents. Unfortunately, objective data is lacking, especially in the U.S. In a recent review paper of glucosamine sufate, the conclusion was that “there are no studies supporting the use of this agent in the U.S. The studies published to date have been done in small numbers of patients; adequate long-term trials examining the safety, efficacy, and optimal dosage requirements of glucosamine sulfate are lacking. Most of the available clinical data are difficult to interpret due to serious deficiencies in study design.”1
There is even less known about their use for patients with normal joints.
The bottom line: although little objective hard evidence exists to support the use of these cartilage supplements, it probably does not hurt to take them. Understand that they may be effective only via a subjective placebo effect. The only known risk at this time is to one’s pocketbook. They are expensive, and as over the counter preparations, insurance companies do not routinely pay for them. I recommend that patients with known arthritic conditions try them for two months without changing other management factors, and if benefit is noted, then continue if desired. However, remember that arthritis is at least in part a mechanical process, and as such, may benefit from mechanical solutions as well.
Reference: da Camara, C.C., Dowless, G.V. Glucosamine Sulfate for Osteoarthritis. The Annals of Pharmacology. 1998; 32: 580-587.
Dan Wnorowski, M.D.
What’s the scoop on a scoop of creatine??
Runners are always looking for an edge. One only needs to look at the covers of running publications to see the eye-catching headlines: “more power!…run faster!…get more energy!…”and on and on. Via nutritional supplements, runners and other athletes hope to gain a physiologic performance benefit via increases in strength, power, endurance, and aerobic and anaerobic capacity, as well as a psychological lift.
The latest hot commodity in performance augmentation is creatine. This is a naturally occurring substance, intimately involved in energy production. The basic unit of energy currency is adenosine triphosphate, or ATP for short. ATP is a unique molecule that is capable of storing energy within its bond to one of its phosphate groups. When muscles, as well as other tissues in the body need energy, the source is ATP. The ATP molecule is cleaved of its phosphate, leaving adenosine diphosphate (ADP), and releasing energy in the process.
To recharge the ADP/ATP battery, ADP must be reloaded with phosphate, and ATP reconstituted. One very quick and effective way this is done within muscle tissue is via creatine-phosphate. Creatine is a substance synthesized in the liver from basic protein precursors. The creatine molecule donates a phosphate to ADP, thereby recreating ATP. Creatine is normally in limited supply, and dependent upon a protein-rich diet.
The current creatine craze is fueled by the rationale that one can increase performance by increasing muscle inventory of creatine. However, despite hundreds of web sites touting its “clear-cut” advantages and “low, low sale prices”, the scientific literature provides conflicting data on this hypothesis, with studies both in support of and against demonstrable benefits. Suffice it to say, any benefits reported to date are most notable during high intensity, short duration activities, like sprinting. There is evidence that best results are noted in those athletes consuming low protein diets, vegetarians for instance. Furthermore, any derived benefits are likely to be tied to enhanced concurrent carbohydrate intake.
The recommended dosage schedule is a loading dose of 20-30 grams/day for one week, followed by ongoing doses of 10-15 grams/day. To get these amounts from one’s diet, one would have to consume the equivalent of ten pounds of raw steak per day for at least ten days.
Although creatine use has its proponents, and its utilization is probably widespread, its safety margin is unknown. Muscle cramping is common, and its use may increase musculoskeletal injuries. A real possibility of kidney damage exists, especially with inadequate hydration, a real concern in runners. There is a theoretical possibility of inhibition of natural synthetic pathways with ongoing long-term use. Late adverse effects are unknown. It is not recommended for use in the recreational athlete, especially in prolonged aerobic exercise activities, like running.
Suffice it to say that for this audience, creatine should be viewed with intellectual curiosity only. It is no substitute for proper training, rest and nutrition. The risk-benefit ratio is potentially high: i.e.- risk>>>benefit. For middle-distance and long-distance runners, it is probably useless, as the body favors other energy pathways. The search for short-cuts and an energy edge will not end with creatine. Beware of deals “too good to be true”.
All of my essays are now available at “www.genufix.com”. I welcome feedback and suggestions for future rantings at e-mail: “genufix@aol.com”. I would be happy to share your tales of woe with fellow STC members on an anonymous basis as a lead-in to discussions of interesting running related injuries and problems. However, I cannot give specific individual advice over cyberspace. A proper evaluation always includes an exam and possibly imaging studies. Always remember that pain and disability should be evaluated if persistent and/or progressive. What may sound like a common and straightforward problem may be anything but in any individual case. Don’t forget common sense. Happy and healthy running!
Dan Wnorowski, M.D.
Heat and COLD Therapy
This discussion, and the next, will focus on the use of therapeutic heat and cold. There is certainly abundant confusion and controversy regarding the indications for and use of these modalities. Hopefully, after these reviews, you will have a better idea about when and where to apply heat and cold treatment to running injuries. Cryotherapy is defined as the use of cold temperature as a form of treatment for an injury. Although cryotherapy dates back to the ancient Greeks (Hippocrates), it is only recently (1940’s) that cold has been used extensively for the treatment of acute and subacute injuries, and rehabilitation.
As we shall see with heat therapy, temperature alterations have four main effects on surface body tissues, including pain relief (analgesia), muscle relaxation, blood vessel alterations, and connective tissue effects. By reducing the speed of impulses conducted by nerve fibers, pain sensations are inhibited by cold. Target temperatures of 10-15 degrees C are recommended. Similarly, decreases in muscle spasm are seen with cold therapy, although the exact mechanisms for this are unclear. It is thought that this result may be mediated through reflex reduction in motor nerve activity secondary to response to increased activity in cold receptors.
With regard to the circulatory system, cold causes constriction of small arteries and veins, by direct stimulation of the smooth muscle lining these vessels. However, a curious reverse relaxing effect occurs with very low temperatures or prolonged cooling. The benefits of vasoconstriction include decreased hemorrhage and swelling within injured tissues, although some animal studies have shown a paradoxical increase in swelling with cold application.
The usual therapeutic techniques include direct application of ice or snow, the use of special cold packs or compression devices (using ice water or cooled water; 10-25 degrees C), cold water baths (hydrotherapy) or cooling topical sprays. These techniques utilize conduction and convection as means of cooling affected areas. General guidelines include the need to protect the skin from cold injury via a layer of intervening material, and limiting exposures to twenty minutes. A convenient schedule is alternating twenty minute periods of application and removal.
Skin and superficial fat is readily cooled by surface cryotherapy, but the effects on deep tissues like muscle and tendon, are somewhat debatable. There is agreement that cooling of underlying muscle requires prolonged exposure exceeding twenty minutes, increasing the risk to the skin. As expected, rewarming of successfully cooled deep tissues takes longer that that of the skin and subcutaneous tissue. Typically, with application of ice, one will experience initial intense cold, then burning sensation, followed by aching and finally, pain relief or anaesthesia (loss of sensation).
Specific techniques useful to runners include direct application of ice to the elevated, injured part, often in combination with elastic wraps or compression devices. Ice massage is a very useful modality: paper or Styrofoam cups containing ice provide a convenient tool, making small overlapping circles of four to six inches for twenty minutes.
Problems with cryotherapy include hypersensitivity and allergic reactions (noted if cold and burning sensations last longer than several minutes), and cold injury, i.e.- frostnip and frostbite. Cryotherapy must be avoided in people with rheumatoid arthritic variants with cold sensitivity, those with skin sensation problems, Raynaud’s phenomenon, cryoglobulinemia, Buerger’s disease, and prior history of frostbite, etc. Caution is necessary when applying cold on or near superficial nerves, or when vigorous activity is expected soon after treatment, especially with prolonged treatment aimed at deeper tissues, such as muscle.
Time to chill…next time, heat therapy will be reviewed.
HEAT and Cold Therapy
Part 2
This discussion will focus on the use of therapeutic heat. As with cold therapy, warm temperature applications have four main effects on body tissues, including pain relief (analgesia), muscle relaxation, blood vessel alterations, and connective tissue relaxation effects. Heat therapy can have both beneficial as well as adverse effects on the tissues, depending upon the magnitude and duration of application.
It is not well known how heat administration reduces pain, but perhaps it is by altering pain nerve fiber conduction speeds, or raising nerve pain thresholds. Furthermore, pain secondary to muscle spasm can be alleviated by direct heat application to tender spastic muscle areas. It is wise to wait until after the acute stages of injury and inflammation subside however, as heat applied early when swelling is prominent can actually increase pain and swelling because of the effects of heat on the blood vessels. Specifically, heat causes a relaxation of blood vessel smooth muscle, thereby opening the vessels and increasing blood flow to the injured region. This phenomenon, combined with direct inflammatory effects, particularly within the skin, mandate a delay in treatment of muscle injury until after swelling resulting from muscle injury has begun to subside. Beneficial effects of increased blood flow to the tissues include facilitation of drainage and a “wash-out” effect, purging the tissues of debris and by-products of tissue injury.
Following muscle, tendon and ligament damage, these tissues generally undergo shortening because of guarded joint positioning due to pain, swelling, and muscle spasm. Typically, rehabilitative efforts are aimed at gradual restoration of joint motion via stretching and gentle range of motion exercises. Heat therapy promotes “relaxation” via lengthening of the collagen tissues within these structures, and thereby aids tremendously in the stretching process.
Burns must be avoided when using heat therapy. Therefore, this technique is not to be used where damaged or abnormally sensate skin is present. As mentioned earlier, heat can increase bleeding in the face of very recent soft tissue injury, such as muscle strains, traumatic tendonitis, and ligament sprains. It can also increase joint swelling if injury is acute. Furthermore, heat should probably also be avoided in children and in women during pregnancy.
General techniques available to runners include conduction (heat transfer by direct contact) and convection (heat transfer via circulation). Hot packs are a form of conductive treatment. Physical therapists often make use of hydrocollator packs, absorptive packs of silica or gel, warmed in hot water baths to over 70 degrees C, wrapped in thick towels to minimize the risk of burns, and applied for 15-20 minutes. These are useful for treatment of joint stiffness and muscle spasm.
Hydrotherapy and contrast baths are examples of convection treatment. Hot tub or whirlpool use ideally includes turbulent flow with water at 38-45 degrees C for 20-30 minutes. Whole body immersion should be avoided at temperatures greater than 40 C (normal body temperature is
In general, after a pulled muscle, joint sprain, or traumatic tendonitis, when swelling is noted, a good rule of thumb is to use cold therapy for the first 48-72 hours (acute period), or until after swelling and pain have peaked. Thereafter, heat therapy may be more advisable, as one enters the subacute phase (3-7 days), or for prolonged symptoms lasting beyond a week.
Dan Wnorowski, M.D.
Analgesics
Pain is all too often an unfortunate part of the runner’s lifestyle. It is virtually a given that a runner will become injured during training and competition, no matter how closely one adheres to the coveted principles of proper training (never too much, too soon, too fast), user friendly footware (fit, function, and fatigue-free), preparation (stretching, cross-training), and cool-down. So what does one do to keep going when the pain tells you otherwise? Usually, one reaches for pain medication, or analgesics.
Medicating an injury requires common sense. Pain is nature’s way of alerting the brain that something is amiss within the body. There are some injuries that should provoke conscious recognition that reaching for the bottle of pills must be accompanied by relative, or even absolute, rest (see: Five Problems You Should Not Run Through). However, for most minor aches and pains, and sprains and strains, the average runner will attempt to persist, while subverting pain signals with aspirin, acetominophen, or anti-inflammatories. We refer to these as “over-the counter” (OTC) medicines, i.e.- they can be purchased at the store without prescription.
Aspirin is probably the cheapest and most traditional of the analgesic drugs. Derived from willow bark and salisylic acid, it is the benchmark of the anti-inflammatory category of drugs. Used sparingly and with caution, it is remarkably effective, and relatively safe, and costs less than candy. It has three basic functions: relieving pain, reducing fever, and blocking the process of inflammation that produces four cardinal signs in injured and damaged tissues: redness, swelling, pain, and heat. However, aspirin on on empty stomach, taken in large quantities, or used in subjects susceptible to stomach ulcers, can be disastrous. Negative side effects include simple irritation of the stomach lining, “gastritis”, or ulcers and bleeding, “peptic ulcer disease”. Bleeding rarely can be brisk enough to threaten one’s life, but aspirin does pose such risk. Two other serious side effects deserve mentioning. Life-threatening allergic reactions (“anaphylaxis”) can occur in certain people with asthma, and reversible ringing of the ears (“tinnitis”) is associated with large doses of aspirin.
Because of these risks, other non-aspirin substitutes have become increasingly popular, especially, acetominophen (TylenolTM). Acetominophen has no such serious risks to stomach and intestine. On the other hand, it has no anti-inflammatory effect, but remains an excellent pain-reliever and fever-reducer. It’s chief problem is possible liver damage when used at doses of more than four grams per day. This is equivalent to eight Extra Strength TylenolTM, or about eleven standard tablets or capsules, per day.
Anti-inflammatory medications also include a category called non-steroidal anti-inflammatory drugs (NSAIDS). These include ibuprofen (AdvilTM, MotrinTM, etc.), and naproxen (AlleveTM). Like aspirin but unlike acetominophen, they have potent effects on reducing the symptoms and signs of inflammation, while also reducing pain. They do carry the risk of stomach irritation and ulceration, though less so than aspirin. They should be used very cautiously in people who have known sensitivity to these drugs or their relations, or in those who have had stomach problems in the past.
Prescription versions of NSAIDS are numerous and varied. They are available at much higher dosages than their OTC cousins, and therefore, pose higher risk to the GI tract. Two new exceptions include the highly marketed, popular favorites VioxxTM and CelebrexTM. These two, available by prescription, work via unique mechanisms which confer a much greater safety level than the classic NSAIDS, and are convenient in that they can be taken only once per day (“long- acting”). However, they are quite expensive (about $2.00/pill), so much so that some managed care companies have often severely restrict their use.
Remember, if you choose to self-medicate, you are consciously choosing to dampen the body’s warning systems. Any persistent or progressive ache or pain should at some point beg the question as to the reason for its presence. Secondly, any drug, no matter how inexpensive, or ubiquitous, has side-effects and risks associated with its use, that must be weighed against its benefits.
All of my essays are now available at “www.genufix.com”. I welcome feedback and suggestions for future rantings at e-mail: “genufix@aol.com”. I would be happy to share your tales of woe with fellow STC members on an anonymous basis as a lead-in to discussions of interesting running related injuries and problems. However, I cannot give specific individual advice over cyberspace. A proper evaluation always includes an exam and possibly imaging studies. Always remember that pain and disability should be evaluated if persistent and/or progressive. What may sound like a common and straightforward problem may be anything but in any individual case. Don’t forget common sense. Happy and healthy running!
Dan Wnorowski, M.D.
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