Pick The Perfect Tri Sports Doc

Bill Vollmar, MD perfect sports doc











"Son can you play me a melody, I'm not really sure how it goes. But it's sad and it's sweet and I knew it complete when I wore a younger man's clothes." Billy Joel

So you didn't used get injured and now you might need to seek medical help? The cover of the December Triathlete Magazine has on it the title of this blog. And it gives a number of good suggestions. But it's neither written nor edited by a physician and maybe another perspective could help.

Triathletes are what's known in MBA circles as early adopters. They'll try things (anything? Compression socks...Biestmilch...dimpled aero wheels) often with minimal proof/history that the new product/technique is actually beneficial, but it might be. On the Slowtwitch site for example, when one forum poster complains of a musculoskeletal problem, invariably one of the "expert" responders notes the obvious need for ART (Active Release). Well, ART is very helpful in the right setting but the nearest practitioner to my house according to the ART website is an hour and a half away!

The two photos above are of Bill Vollmar, MD, seemingly "only" a Family Practitioner from Lancaster, PA and some would say might have trouble spelling triathlon. But he is whip-saw smart, takes care of almost exclusively athletes, and since unlike me he's not a surgeon, would likely have a non-surgical solution to almost any injury if it's feasible. Only as a last resort would he consider involving someone who might want to cut on you! And, he is so good that he could take care of me and my entire family. And lord knows I've had more than my share of musculoskeletal problems - compartment syndrome, plantar faciitis, achilles tendonitis, rotator cuff tear, I could on. The take home point is that, at least for many of us, we don't have to drive hours to the Pro from Dover with the treadmill for a good portion of our medical needs, we just need to know what's available locally. In fact, like many locations, the go to guy here for most running induced issues is the owner of the running shoe store. With 27 years of seeing runners problems he could take care of the Olympic team! And I'll bet there are examples of this in your community, say the kids swim coach who's been working on swim strokes for decades.

So, as pointed out in Triathlete, don't be embarrassed to ask around to see what's available, who's available, for your specific problem. Help could be right around the corner...and his name might be Bill Vollmar.

Carpal Tunnel...Hand Numbness

If you look carefully, you can see this very inventive athlete has put clear packing tape over the holes on the front half of his helmet to convert it to a partial aero helmet yet leaving the rear half open for air and water dousing. Very clever.



WARNING: A local motorcyclist was killed this weekend when a deer ran into him! In many parts of the country hunting season is open and it may change animal behavior. A few years ago, on a pre-dawn run, one of my children actually ran into a deer. So, please be extra cautions, extra vigilant out there and don’t just go bombing down a hill without paying great attention.


CARPAL TUNNEL


Many athletes experience significant hand numbness while astride their bike. Often this involves the thumb, index and long fingers and with a change in hand location or position this feeling dissipates. The distribution of this numbness is in the median nerve as can be seen in the accompanying picture (WebMD).
This can also be accompanied by a feeling of tingling but when these feelings go away completely off the bike, it's no real cause for concern. Those who progress to weakness, occasionally dropping items, night time numbness, etc. may benefit from evaluation. The chronic case will often be accompanied by atrophy of the muscles at the base of the thumb. This condition can accompany pregnancy, diabetes, obesity,arthritis and other illnesses.

Evaluation consists of an examination of both upper extremities, neck, pulses and sensory. Although occasionally obtained, usually x-rays are not helpful in making the diagnosis. A neurologist can perform a nerve test known as an EMG to determine if there's compression of the median nerve by a ligament in the wrist thus slowing nerve function. In some cases, blood work is also helpful.

The treatment options are pretty wide, depending in the diagnosis, and whether or not the CTS is secondary to one of the causes listed above. Many benefit from simple night splints, mattress change, biking hand position change, or other mechanical alteration. But, unfortunately a release of the pressure on the nerve by releasing the ligament is in order for others. When indicated, it's a highly successful procedure but we try to avoid surgery when there are other alternatives.

Pool Running Can Be Fun

"You got to do what you can, and let Mother Nature do the rest." Meat Loaf



At some time in our careers, water running, or aqua jogging, will be recommended as a method of cross training injured athletes. Others find it an ideal form of non-impact aerobic training. Basically, you "run" in water that's deeper than your limb length. This can extend from the diving well up in to the lanes, with a flotation vest or belt to increase buoyancy...so you don't drown. Although most run the length of the available area, others attach themselves, say to the ladder, and run in place. Running with a partner provides easy conversation, or, a water proof source of music may be of benefit. One attempts to mimic one's form as closely as possible to that used on land. Mimicking run duration and intensity is also important. For example, if you're scheduled for 45 minutes of steady running, do 45 minutes in the water. As you'd imagine, heart rates will be lower but many find that they can come within about 10 beats/minute of their land running. It's possible to run intervals repeating levels of intensity done on land.

Athletes have shown that not only can they maintain their level of fitness, but with dedication can actually improve. This comes into play when one begins to return to the road. Initially, shorter workouts can be supplemented with time in the water keeping the workout time "whole."

Again, it's a priority to duplicate your form on land, arm swing, head position, elbow engagement, etc. If your pool has both vests and belts, you may find one or the other allows you to more easily maintain this action. Your hip flexion will likely increase in the pool giving you an artificially lengthened "stride."

Like many, I am currently water running at the end of my swim workout. And, watching the others in my swim group continue to turn out the yards is all the distraction I need to stay focused. And, I can still joke with the lifeguards while I'm running!"

Blood Thinners and Blood Clots

Testing an athlete's serum lactate levels while pedaling under a controlled load and controlled conditions is one way to determine the lactate threshold and from that one's training zones. If this athlete takes a blood thinner, would testing of this sort put him or (and possibly as important in these litigious times) the test director in jeopardy?


Blood is drawn from the athletes left ear lobe at 3 minute intervals during testing.

I fail to be surprised each time I see/hear about another athlete who's taking blood thinner medication for a recent, and some cases not so recent clot. There are frequent reports in a number of the on line Tri forums and I thought a review would be beneficial.

A pulmonary embolism or clot in the lung (sometimes air or fat, etc.) can be fatal! A person with an acute PE can complain of chest pain, often worse with deep breathing, the onset of a cough which may contain blood tinged sputum and they can breathe more rapidly. They may note both a shortness of breath and more rapid heart rate. This is obviously an emergency - go to the hospital - and treatment will be initiated to prevent new clots from forming, start oxygen, and occasionally clot busting meds will be given. A frequent source of clot can be the legs, say there's been a long airline flight (like to Kona), long car ride, etc. Other risk factors include birth control pills, positive family history, recent orthopedic surgery, cancer, etc. Prevention would obviously be the best choice as once diagnosed, there will likely be a 3 - 6 month period where blood thinners are taken on a daily basis and the blood is drawn at regular intervals to make sure the medication is working correctly. It's called Coumadin and is the active ingredient in rat poison believe it or not.

To prevent a PE, when you are on a long drive/flight get up and move around frequently, move your legs. Bed ridden patients in the hospital can be fit with devices that squeeze the foot or calf to keep the blood moving and prevent pooling.

Triathletes ask about racing and training while taking Coumadin understanding that they are at increased risk for bruising, bleeding -both external and internal - and that any cut or abrasion on the skin will bleed more. Once the Coumadin dosage has leveled off and the medical team feel the clot stabilized, then a return to training can be considered. I don't think anyone would take issue with swimming or strength training, and probably not running if the return to the roads is done slowly and carefully. Biking, where the potential for a crash (read injury) is higher, gives us the biggest worry. All of us have crashed at one point or another and in one of my previous blogs I reported being momentarily unconscious after my helmet contacted the asphalt unexpectedly. I am very glad I wasn't Coumadinized when that happened because of the risk of bleeding into my head and permanent damage. I believe I'd be inclined to ride the stationery bike watching old TdF videos for quite some time.

Lastly, the question of eating green, leafy vegetables comes up as they have plenty of vitamin K and vitamin K reverses the blood thinning action. Most people would agree that if your diet is constant, eating about the same amount of greens daily, that you should be ok and it's those patients who have a big salad one day (the day prior to their blood test could be a problem) but chili cheese dogs on the the other days. Keep it even.

In short, prevent those leg clots by moving around on long trips and, if for any reason you think you might have a PE, get to the hospital pronto, it's the best course for you.

Overuse Injuries

Destinations probably not seen near your hometown.





"Wish I didn't know now what I didn't know then." Bob Seger

Continuing the theme of self induced problems, having discussed stress fractures and the like previously, this weeks blog will focus on potential ways to avoid ending up at the doctors with what may be an avoidable problem.

Last week, I gave you an example of athletes who just can't turn it off. A local runner of some renown, while rehabing a problem for which she'd ended up in the operating room, was widely known for doing her morning training...following doctors orders...and then seeing if she couldn't find someone else to go running with her that afternoon in what most likely will never see the light of day in her training log. Nor will it be revealed when reporting back to the doctor if things don't go well.

In that this is November, and many of us have taken a break from training or are about to do so, we get the opportunity to review 2009's results, both good and bad, as we prepare for 2010. We're getting ready to create a road map starting from today and ending up at the finish line of our "A" race(s)and beyond. We are sort of Mapquesting the directions to our 2010 athletic goals. If we follow the periodization model, we're setting up a basic skeleton to control our training volume and intensity so that we're "all we can be" come race day. When the training year is created with this much planning and care, the potential for overdoing it, both in the short and long haul, is diminished. Both training hard and resting hard are accounted for in your long term plan.

Our bodies can perform at almost any level if we prepare them adequately. One of the first books I read on marathon training 30 years ago was a steady increase in long runs, each week harder than it's predecessor, until your chosen race. I don't recall the author ever referring to the "R" word. Rest. If you think about Achilles Tendon problems, plantar faciitis, runners knee, stress fractures, etc., you grab a big group of problems that, for the most part, are the result of training in a fashion in which the body is unprepared. They didn't need to occur.

So, I would ask you to write down the basics of your training for the next 11 months starting backwards from the "A" race. If you'd like a model to follow simply look at the year put together by Joe Friel in the "Triathlete's Training Bible" or go to www.trainingpeaks.com and have the computer generate one for you.

But, have a plan. Oh yeah, and don't forget the "R" part.

Patience For Improvement

Not everyone who comes to Kailua Bay during Ironman race week wears a Speedo!



"I'd take any risk to turn back the hands of time." Styx
I didn't race at IMH this year...and likely my body's been sending messages loud and clear that I'm done with iron distance racing. But on Sunday morning after the event, I went for a bike ride and was astonished to see a couple runners. Pushing it! At first I thought they were tourista like me but as I approached, I could see that they both had Ironman wrist bands on and a race day sunburn on their neck and shoulders from an especially hot day yesterday for the race. (There's almost no shade on the Big Island bike route. Maybe one could ride in the shade of an overflying seagull...but that would present it's own potential hazard!)

Running? The day after IMH? What were they thinking? Were they thinking? Maybe getting a jump start on training for their next iron distance race...next weekend. Or, maybe they're just not able to turn it off.

Racing and training at this level causes significant breakdown of bodily systems that need recuperation time be it from training or racing. Although there are a select few who can get by with less...and these are the ones we hear about in the press...most of have neither a red cape nor an "S" on our chests. And Kryptonite doesn't bother us one bit.

Why not take the first several days after a race to let the soreness fade, blisters, if present resolve, and only then begin a few low effort, short workouts focusing on form and style, not quantity. Many would suggest that it be a full 10-14 days before getting back into full training after a 140.6 effort, assuming you already have a race scheduled. That time would be well spent on family activities, reading (no, not about triathlon), maybe even go see the new Michael Jackson movie for something completely different. Or, if you're a guy, take your spouse to a chick flick like "Julie and Julia." I took my wife. And I liked it. Maybe it's time to simply be a husband and father/mother and wife, and not an athlete. Although no one would fault you for drifting into thoughts about HED wheels during the credits.

Firecrackers Thrown at Cyclist

Yes, they have Halloween, even in Kona, Hawaii.

Those of you who read my blog know that it's all about exercise safety in addition to caring for the injured athlete. One of our better local triathletes was beginning a ride near his home last week when a slow moving minivan approached with the sliding side door open. At first the biker heard explosions to his right and then very quickly they hit his shoulder and neck! As the driver sped away, the athlete took chase. But who can catch a car on their bike?

Unfortunately for this driver, he passed the athletes wife in her car at the next stop sign where a quick cell phone call from our boy allowed her to follow the van getting the license # and a description of the driver. He was apprehended that evening and a confession quickly followed. Charges have been pressed against the 11th grader from a nearby high school, and since he's under 18 and this is his first offense, he'll avoid court and go straight to the probation officer. As the athlete noted, "I make my living as a pilot and can't afford to lose my hearing or eyesight."

Our athlete was uninjured, although I suspect many of us - me included - would have crashed or run into a phone pole if the firecrackers were thrown at us. I believe I might think some one was trying to kill me. So what do we learn from this? Always carry your cell phone. Get in the habit of looking at license plates, even jot them down, which is easy to do if you keep pen and paper in your fanny pack with your emergency first aid kit. Don't confront rude drivers alone.

It's easy to think about retribution, about getting even, about finding those who run us off the road and putting a potato in their exhaust at night or flattening the tires on their car...or worse! But our goal is to live to ride another day and some of those folks on the road where I live might be just crazy enough to run me into the weeds if they thought I'd done something to them. Or worse, they'd run you into the weeds for something I did. And then we'd all lose.

Be careful.............. it's a jungle out there.