Download to - American Running Association

RUNNING & FITNEWS®
September / October 2007 • Volume 25, Number 5
Marathoning with Mitral Valve Prolapse
The mitral valve is one of the four valves of the heart, and it is located between the left atrium (where
the blood flows from) and the left ventricle (where the blood flows to). It is the only valve with two
small flaps, known as cusps; it is therefore sometimes called the bicuspid valve.
The mitral valve normally stops blood from flowing back into the atrium. A mitral valve prolapse
(MVP) occurs when one or both of the flaps stick out back into the atrium during the normal ventricular
narrowing that is designed to push blood into the aorta. When a flap sticks out, the valve fails to close
properly and blood flows back into the atrium.
Most patients with MVP are asymptomatic. Some patients feel chest pain, irregular heart rate, weakness,
or breathing difficulty. In severe prolapse cases, the leaky valve forces the heart to work harder. Over
time damage can occur, including a swelling of the left side of the heart, known as valvular heart disease
(VHD).
Mitral regurgitation (MR) is often but not always the result of MVP. It is considered an independent
entity medically and can be a more severe condition that involves a lesion of the mitral valve, often from
a birth defect. It too means that blood is leaking back into the atrium; the primary difference is the
severity of the leak. MR is associated with definitive symptoms of breathing discomfort, irregular heart
rate, and fatigue. Treatment depends on the dangerousness of the condition, and can include valve repair
surgery in some cases where congestive heart failure may be occurring.
Unforeseen Athlete Deaths
On October 7, 35-year-old Michigan resident Chad Schieber collapsed and died during the Chicago
Marathon. He was physically fit. His sister-in-law told reporters that he helped train police officers to
become bicycle patrolmen. An autopsy revealed that Chad had MVP. This incident reminded many of
another Chicago Marathon death: On October 13, 2003, Rachael Townsend, 29, also of Michigan,
collapsed and died after a 3:40 finish in that race. Townsend taught physical education and coached
soccer for six years. She was often spotted doing laps around the school's track and jogging around
town. She, too, had MVP.
Unlike Jim Fixx or Danny Towns, the 45-year-old Oklahoma man who collapsed a few miles from his
Chicago finish, these runners were not reformed smokers or previously overweight. Like Jim Fixx,
Towns’ autopsy revealed coronary arteriosclerosis.
So what is occurring here? What are the recommendations for people with MVP? How can they make
intelligent decisions about fitness activity, and why does there sometimes seem to be a conflict between
those recommendations and how things play out on race day?
First, be sure that the risk of sudden cardiac death in athletes, even those with underlying cardiovascular
disease, is extremely low. Of the 10 to 15 million athletes of all ages who participate in organized sports
each year in the United States, fewer than 300 die of cardiovascular-related causes. However, sudden
cardiac deaths in competitive athletes are highly visible events. Sudden deaths have occurred in athletes
of both sexes, in minorities, and in a wide range of ages and sports (most commonly basketball and
football in the United States).
1
The Recommendations
The American College of Cardiology (ACC), in conjunction with the American Heart Association
(AHA), releases guidelines from time to time to assist doctors and the general public in their assessment
of appropriate physical activity for people with cardiovascular abnormalities.
“Ventricular arrythmias” refer to a set of conditions associated with abnormal functioning of the walls
within the heart cavities, relating to contraction and wall motion. Of these, ventricular fibrillation is the
most serious. It is marked by a very fast, very uneven heart beat during which blood pressure falls to
zero, the patient goes unconscious, and death may result within four minutes, unless defibrillation and
ventilation are initiated immediately. Ventricular tachycardia refers to a fast heart beat that usually
originates in a specific network of muscle fibers spread throughout the heart known as the Purkinje
system. Ventricular tachycardias are faster than 100 beats per minute by definition.
In a 2006 publication focused on reducing incidents of sudden cardiac death in athletes with ventricular
arrhythmias, the ACC/AHA stated that there is insufficient data demonstrating reduction in ventricular
arrhythmias as a result of mitral valve repair or replacement in most patients with valvular disease
(including severe MVP, severe MR, or serious ventricular arrhythmias). For these reasons, patients with
VHD and ventricular arrhythmias should be evaluated and treated following current recommendations
for each disorder. Those recommendations in turn state that:
“In most patients, the MVP syndrome is associated with a benign prognosis. The age-adjusted survival
rate for both men and women with MVP is similar to that of individuals without this entity. Sudden
death is a rare complication of MVP, occurring in fewer than 2% of known cases during long-term
follow-up, with annual mortality rates less than 1% per year. The likely cause is a ventricular
tachyarrhythmia…a normal lifestyle and regular exercise are encouraged for most patients with MVP,
especially those who are asymptomatic.”
The report goes on to say that whether exercise-induced ischemia develops in some patients with MVP
remains controversial. Restriction from competitive sports is recommended when moderate left ventricle
enlargement or dysfunction is noted. Also, uncontrolled tachyarrhythmias, prior resuscitation from
cardiac arrest, or aortic root enlargement “is present individually or in combination.”
The above recommendations come from a 2006 publication focused on management of patients with
VHD and developed by the ACC/AHA in collaboration with the Society of Cardiovascular
Anesthesiologists, and endorsed by both the Society for Cardiovascular Angiography and Interventions
and the Society of Thoracic Surgeons.
Similarly, the 2005 ACC/AHA task force report on eligibility for competitive athletes with
cardiovascular abnormalities recommended that “athletes with MVP—but without high risk features—
can engage in all competitive sports.” Those features include prior fainting spells, thought to be due to a
rhythm disturbance, family history of MVP-related sudden death, severe MR, abnormal left ventricular
pump function, a prior stroke, or repetitive, complex heart rhythm disturbances.
Chicago 2007
So now let’s look at these marathon-related deaths in Chicago further.
The 2007 race saw the highest temperatures not only in Chicago Marathon history, but, at 88 degrees,
record temperatures were recorded for October 7 in general. Race officials cancelled the race, also for
the first time in the Chicago Marathon’s history, after just three and a half hours. Some 315 runners were
2
taken from the course by ambulance with heat-related conditions. Five people remained hospitalized in
serious or critical condition that Sunday night. Runners described chaotic scenes of racers throwing up,
passing out or being carted away on stretchers. Of the 35,867 runners who started the race, just 24,933
finished.
And here is what the newspaper had to say in 2003: “With a high of 71 degrees, Sunday ranked among
the warmest Chicago marathons ever… Dr. Greg Ewert, the Chicago race's medical director, said the
warmer weather made the medical tents at the finish line busier than usual… Many of those treated in
the tent after the race had heat exhaustion and up to 104-degree body temperatures, typified by
symptoms of fatigue, nausea, cramping and disorientation. Others had heat stroke, with temperatures
above 104.” The medical director went on to report that those who felt sick were sicker than usual. This
statement speaks to the heart of the matter.
Physicians almost universally agree that MVP in and of itself is not the cause of these athlete sudden
deaths; there are almost always other causes involved. The heart problem blamed in the death of Chad
Schieber is rarely dangerous and people who have it shouldn't stop exercising. As cardiologist Phillip
Watkins, MD, puts it, ''People are not dying in the streets because they have mitral valve prolapse.”
Watkins works in a Birmingham, Alabama, center that specializes in treating the problem.
Experts make a distinction between MVP and severe MVP. If the condition is mild, it requires no
treatment. If it is severe, an operation can be done with low risk. The Chief Medical Examiner in Cook
County reported that Schieber had ''significant mitral valve prolapse.'' And while an autopsy found the
death was not related to heat stress, the high temperatures that day undoubtedly contributed to
Schieber’s demise. Dehydration could have been a factor. The victim's family said Schieber encountered
at least one water station that had no water.
Running a marathon even on a hot, humid day wouldn't be extraordinarily dangerous for most people
with MVP, assuming they trained and stayed hydrated during the race. But athletes with any type of
heart condition can be more susceptible to heat and dehydration.
Rarely, MVP can cause a sudden rupture in the fibrous tissue connecting the valve to the heart muscle,
leading to severe leakage of blood into the lungs. Robert Bonow, MD, who is chief of cardiology at
Northwestern University's Feinberg School of Medicine, says, ''That can be fatal, especially under
extreme circumstances, such as exertion or hot weather.”
Complicating Factors
Significant mitral regurgitation can be caused directly by MVP. If severe enough, MR can lead to
enlargement of the cardiac chambers, weakening of the heart muscle, and ultimately, to heart failure.
Fortunately, MVP tends not to cause significant MR. Only about 5% of patients with true MVP develop
it in their lifetimes.
However, systematic training in endurance sports may trigger physiologic adaptations and structural
remodeling of the heart, including increased left ventricle wall thickness, cardiac mass, and cavity
dimensions. This is often referred to as "athlete's heart". Other potential adaptations include a variety of
abnormal ECG patterns, which can mimic those of cardiac disease. These adaptations are seen in some
40 percent of elite athletes. Frequent or complex ventricular tachyarrhythmias are not uncommon in
athletes and also are similar to symptoms of cardiac disease.
Furthermore, running a marathon injures muscle tissue, triggering an inflammatory response that makes
the blood more prone to form clots that can cause heart attacks. Arthur Siegel, MD, of McLean Hospital
3
in Massachusetts took blood samples from 80 Boston Marathon runners before and after the race. The
morning after, he found elevated levels of inflammatory and clotting factors in the runners' blood.
These ambiguities in the relationship between intense physical activity and heart health contribute to the
public’s misperception of MVP and marathoning as a dangerous mix. Another complicating issue may
be that race officials do not want to be held responsible for athlete deaths in extreme temperatures, and
so can be tempted to blame a person’s well-documented, lifelong medical condition to explain the death,
at least to the media.
What to Conclude?
Remember that training demands vary considerably even within the same sport. The demands of
competitive sports may place athletes with certain cardiovascular abnormalities in extreme or
unpredictable environmental conditions. These can be associated with alterations in blood volume and in
hydration and electrolyte levels, circumstances which could enhance the risk of potentially lethal
arrhythmias.
However, because MVP is common, it has been associated with a myriad of conditions that probably do
not have anything to do with the MVP itself. While it is commonly believed that MVP causes chest pain
and heart palpitations, most individuals with MVP do not experience them.
It is not at all clear that mild MVP is in any way associated with sudden death, let alone a cause of it. A
small number of patients with MVP will eventually develop significant MR, which in turn can produce
heart muscle weakness—and these patients do have an increased risk of life threatening arrhythmias.
This is why it is vital to distinguish MVP from MR, even if the one can occasionally cause the other.
Patients with severe mitral regurgitation—from any cause—have an increased risk of stroke and sudden
death, but the vast majority of patients with MVP have never been shown to have any higher risk of
sudden death than the general population, and the recent tragedies in Chicago should not cause undue
concern.
If you do have MVP, make sure you understand from your physician the degree of MR that you have.
It’s also important that your doctor has a schedule for outlining and monitoring this degree over time. If
you have chest pain or palpitations, these symptoms ought to be evaluated as separate entities.
REFERENCES:
“Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities,” J Am Coll
Cardiol, 2005, Vol. 45, No. 8, pp. 1318-1321, http://content.onlinejacc.org/cgi/content/full/45/8/1318;
“Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden
Cardiac Death,” J Am Coll Cardiol, 2006, Vol. 48, No. 5, pp. 1064-1108,
http://content.onlinejacc.org/cgi/content/full/48/5/1064;
“Guidelines for the Management of Patients with Valvular Heart Disease,” J Am Coll Cardiol, 2006;
Vol. 48, No. 3, pp. e1-e148, http://content.onlinejacc.org/cgi/content/full/48/3/e1;
Mosby Medical Encyclopedia, revised ed., 1992, Plume, pp. 510, 818;
American Family Physician, 2005, http://findarticles.com/p/articles/mi_m3225/is_3_72/ai_n14888498;
“Does Mitral Valve Prolapse Cause Sudden Death?” by Richard N. Fogoros, MD, About.com, October
9, 2007, http://heartdisease.about.com/b/a/254777.htm,
http://heartdisease.about.com/cs/mvp/a/MVP.htm;
4
The Texas Arrhythmia Institute, http://www.txai.org/edu/irregular/ventricular_tachyarrhythmias.htm;
“Runner's Death Still a Mystery,” Chicago Tribune, October 15, 2003;
“Man Dies in Heat-shortened Marathon,” by Josh Noel, Andrew L. Wang, and Carlos Sadov, Chicago
Tribune, October 7, 2007;
“How Marathons Can Kill You,” by Jim Ritter, Chicago Sun Times, October 6, 2002;
“Runner's Heart Defect Usually Not Fatal,” AP, New York Times, October 9, 2007
Blood Test for Alzheimer’s Yields Promising Preliminary Results
In mid-October scientists announced the development of a blood test that can accurately diagnose
Alzheimer’s disease years before debilitating memory loss occurs.
The test, which was developed at Stanford University, is 90 percent accurate and distinguishes the blood
of people with Alzheimer’s from the blood of those without the disease. The test was about 80 percent
accurate in predicting which patients with mild memory loss would go on to develop Alzheimer’s
disease two to six years later.
The medical community is calling the results very promising but nevertheless preliminary. The work
must be validated by larger studies, in particular because there have been many disappointments in the
past. The search for “biomarkers” in Alzeheimer’s disease diagnostics is furtive and ongoing, and often
leads to early announcements that don’t always live up to their expectations.
Alzheimer’s is currently diagnosed by a battery of mental and other tests, an inevitably subjective
process. Doctors agree that it would be very useful to have something like a pregnancy test for
Alzheimer’s—one that is simple and definitive and can pick up the disease very early, maybe even
before symptoms appear.
People do not agree universally about the value of early diagnosis for Alzheimer’s disease, due to the
present ineffectiveness of treating it. Some people simply do not want early notification that they have
an incurable ailment. But other people want to know what their future holds so they can plan their
estates and other aspects of their lives. However that aspect of early diagnostics plays out on an
individual basis, the real usefulness of such a test comes once drugs are developed that slow or halt the
progression of the disease, several of which are now being tested. The drugs would be most valuable if
they could be used before cognitive ability has declined too much.
The Stanford group found evidence from animal studies that brains affected by Alzheimer’s send out
signals to the body’s immune system. The team decided to focus on proteins in the blood that are
involved in communication between cells, hoping to eavesdrop, as it were, on “dialogue” related to
Alzheimer’s. The researchers gathered over 200 blood samples from people with Alzheimer’s and those
without. Using 83 of the samples, they measured the abundance of 120 proteins involved in cell
signaling and found they could distinguish the Alzheimer’s samples from the controls using 18 of the
proteins. They then tested their 18-protein signature on another 92 samples. The tests agreed with the
clinical diagnosis about 90 percent of the time.
5
Based on samples from 47 patients with mild cognitive impairment, the researchers were also able to
predict with roughly 80 percent accuracy whether a patient went on to develop Alzheimer’s two to six
years after the blood sample had been collected.
(“Progress Cited in Alzheimer’s Diagnosis,” by Andrew Pollack, New York Times, Oct 14, 2007)
For Cancer Screening, There’s No Substitute for Colonoscopy
Colorectal cancer is the second leading cause of cancer death (the first is lung cancer). Early detection
could reduce mortality by as much as 60%. Colonoscopy, however, remains far from routine: a study in
The Archives of Internal Medicine found screening rates of only 18% among 500,000 Medicare
recipients for the year 2002-2003.
Contrary to popular conception, colonoscopy need not be painful or uncomfortable. The procedure is
now usually performed at your doctor’s office under sedation, and is typically painless. While the
procedure requires a 24-hour fast with oral laxative to cleanse the bowels, it no longer requires drinking
the vast amounts of foul-tasting liquid it once did. A single serving of laxative is usually all that is
required, and even the impossibly frequent trips to the bathroom and painful bloating that patients once
experienced are largely a thing of the past.
The test takes roughly 30 minutes, and involves the insertion of a camera-tipped tube into the anus to
inspect the interior walls of the entire colon. Colonoscopy allows doctors to see potential lesions or
polyps and remove them for biopsy on the spot, making it unsurpassed in colon cancer screening
efficacy.
If you’ve tested normal in a fecal occult blood test (FOBT), which checks for trace amounts of blood in
the stool (a sign of many possible conditions, including cancer), you should not assume you don’t need a
colonoscopy; precancerous and even cancerous polyps do not always cause bleeding. Another concern is
that by the time bleeding is detected, the cancer may have become considerably more dangerous. The
Gastroenterology Division at the Johns Hopkins Bayview Center recommends a colonoscopy every five
years for people age 50 and up. (Annual FOBTs are still a good idea.)
“Flexible sigmoidoscopy” was used frequently in the past but not much anymore. Using only two feet of
tube reaching to the sigmoid, or end portion of the descending colon, this test is less accurate, and
cannot immediately perform biopsies on any detected polyps.
One promising development is virtual colonoscopy, which scans the abdomen while an inserted tube
pumps air through the rectum and colon. This is known as a CT colonoscopy, and it produces 2D and
3D images more detailed than the standard x-ray machine. While less invasive, some people report mild
discomfort during the procedure. Furthermore, a 24-hour bowel preparation is still necessary. In one
study comparing CT to standard colonoscopy, CT found 39% of lesions greater than or equal to 6mm
(considered dangerous) and 55% of 10 mm or larger. Colonoscopy detected 99% and 100%,
respectively. Like sigmoidoscopy, CT colonoscopy cannot perform immediate biopsy. If a polyp is
detected, a colonoscopy still becomes necessary.
(Health After 50, 2007, Vol. 19, No. 5, pp. 6-7)
6
Cutting Through the Haze of Health Marketing Claims
Televised direct marketing, niche advertising, and the Internet have all aided in the proliferation of
health fraud, dubious medical claims, fad diets, and other pseudoscientific hokum designed to extract
millions of dollars a year from the health conscious. For candid, unbiased analysis of health claims,
consider www.quackwatch.org, an independently run web site with an abundance of well written
articles that hold various medical claims up to the rigorous standards of scientific research.
Founded in 1969 as the Lehigh Valley Committee Against Health Fraud, Quackwatch, Inc. was
incorporated in 1970. Affiliate web sites include: Acupuncture Watch, Autism Watch, Cancer Treatment
Watch, Chirobase, Infomercial Watch, and Diet Scam Watch. The National Council Against Health
Fraud co-sponsors the free weekly newsletter of Quackwatch.
A 30-year member of the Consumer Federation of America, in 1997 the Chapel Hill-based organization
assumed its current name and began developing a worldwide network of volunteers and advisors. The
medical advisory alone is composed of some 67 members. Other advisors include nutritionists, dentists,
mental health advisors, veterinary advisors, and scientific/technical advisors. In a nutshell, Quackwatch
investigates questionable health claims and reports misconduct, such as illegal marketing or misleading
advertising, within the health community. At the same time, when an entity is shown to be a reliable
source of medical information, Quackwatch is not afraid to announce it: www.quackwatch.org also
provides links to hundreds of trusted health sites.
Quackwatch.org is divided into easily navigated categories, for example, “Consumer Strategy: Health
Promotion,” within which a dozen or so concisely written, highly informative articles appear alongside
their original publication dates. Topics range from Dietary Guidelines for Infants to Choosing Exercise
Equipment. There are articles debunking the evidence against fluoridation of tap water, practical advice
on checking a physician’s credentials, and a study of current scientific consensus on antioxidants and
phytochemicals.
Quackwatch is the brainchild of Stephen Barrett, MD, a retired psychiatrist, scientific advisor to the
American Council on Science and Health, and a Fellow of the Committee for the Scientific Investigation
of Claims of the Paranormal (CSICOP). In 1984, he received an FDA Commissioner's Special Citation
Award for Public Service in fighting nutrition quackery. In 1986, he was awarded honorary membership
in the American Dietetic Association.
Addressing critics who accuse him of unbalanced reporting, Dr. Barrett writes, “Balance is important
when legitimate controversy exists. But quackery and fraud don't involve legitimate controversy and are
not balanced subjects. I don't believe it is helpful to publish ‘balanced’ articles about unbalanced
subjects…The information Quackwatch provides is not filtered by editors who are too timid or believe it
is politically incorrect to provide the naked truth about theories and methods that are senseless. When
discussing conflicting viewpoints, we indicate which ones are the most sensible.”
For an opinion representative of what may be called the “Quackwatch approach,” consider Barrett’s
answer to the question, Do you believe there are any valid "alternative" treatments? “This question is
unanswerable because it contains an invalid assumption. ‘Alternative’ is a slogan often used for
promotional purposes, not a definable set of methods. Methods should be classified into three groups:
(1) those that work, (2) those that don't work, and (3) those we are not sure about. Most described as
‘alternative’ fall into the second group. But the only meaningful way to evaluate methods is to examine
them individually, which we do.”
7
Quackwatch has defined the scope of its investigations clearly, and indicates that it is not focused on
medical malpractice. Barrett says, “Our focus is on fraud and quackery. Malpractice is the failure to
meet mainstream standards of care. Fraud is deliberate misrepresentation. Quackery, as we define it,
involves the promotion of unsubstantiated methods that lack a scientifically plausible rationale.
Although some overlap exists, most cases of malpractice involve negligence rather than fraud or the
promotion of bogus methods. We focus on information that is difficult or impossible to get elsewhere.”
A minor quibble with www.quackwatch.org is that the site does not seem to be updated quite enough.
But given the volume of dubious medical claims reaching the market every day, it is astounding that
they have kept up as well as they have. The articles that do appear on the site are clearly labeled by date,
which helps the reader assess current controversy independent of claims that have been soundly
debunked and have disappeared from public discourse. And the sheer abundance of well sourced articles
is surprising for what may be in essence viewed as an unfunded passion project. Where the
comprehensiveness falls short, the links to other sites with the relevant information are abundant.
So what lifestyle choices has Dr. Barrett made for health and longevity? He says, “My diet is about 10%
fat and adequate in fiber. To keep fit, I do 2-4 sessions of aerobic exercise per week. On some days, I
use a treadmill, exercise bike, and Nordic Track for a total of about 40 minutes. On other days, I swim
about 1,500 yards in half an hour.” Not surprisingly, the program has resulted in excellent cholesterol
levels and a resting pulse of 54.
For an example of the type of articles Quackwatch offers, see What is the True Value of Buying
“Organic” Foods? in this issue.
(Quackwatch, Inc., www.quackwatch.org)
Leaving Knee Pain Behind
By some estimates the number of Americans identifying themselves as runners has now grown to some
40 million. With roughly a third of the injuries treated annually for these dedicated followers of fitness
affecting the knee, and roughly 60% of those runners suffering an injury in an average year, odds are
one in five that you’ll experience a knee pain or a knee injury in one 12-month period of training.
So how can we mitigate the inevitable knee problem awaiting us down the long and winding road?
Kevin Plancher, MD, orthopedic surgeon for the US Ski & Snowboard teams says, yes, of course
running puts stress on the knee, which is the largest joint in the body and one of the most easily injured.
But this doesn't spell automatic trouble. "The key is to understand your body's mechanics and pay
attention to any signs that your knees aren't moving properly," he says.
The knee joint comprises three bones: the femur (thigh bone), the tibia (shin bone), and the patella
(kneecap), which slides in a groove on the end of the femur. It also contains large ligaments connecting
the bones to each other and helping them move correctly. Tendons connect the bone to muscle, and
cartilage cushions everything and helps to absorb shock.
Knee problems in runners can often be traced to a few key factors:
Overuse. Any repetitive activity can fatigue your muscles and lead to excessive loading of the joints,
which need time to repair themselves. Inflammation and damaged tissue are par for the course after hard
workouts, and so if you don't rest enough between them, either by scheduling easy days or days of
8
altogether rest, the cycle of inflammation, damage, and diminishing returns puts you at increased risk of
injury.
It’s important to assess your “readiness to run” on any given day. Generally, you should not push past
what your body is telling you it can do. You’ll only render the next day a day of flat-out rest, when it
could have been another training day.
Lack of strength and flexibility. If your leg muscles are tight and/or weak, they won't absorb enough of
the stress exerted on your knee joints. A long warm-up is useful here and can also help you assess the
delineation between what you feel like doing and what your body is capable of doing, safely and injuryfree. But many people avoid strength training those supportive structures around the knee, blaming the
joints when really it is the muscles’ inability to take up the job of shock absorption that causes undue
joint stress. Put simply, weight training is a vital component of knee pain avoidance.
Mechanical problems. Having certain structural abnormalities, such as a malalignment of your knees,
flat feet, or a leg length discrepancy, can leave you more prone to knee problems. Be sure to get a
biomechanical assessment from a sports medicine doctor at the earliest onset of knee pain. (S)he may be
able to recommend a corrective shoe, orthotics, or other solution to keep you training pain free.
Overweight. Carrying around even a few extra pounds increases stress on your knee joints. It can also
put you at increased risk of osteoarthritis by accelerating the breakdown of joint cartilage.
If you experience knee pain that isn't severe or disabling, try taking a few days off from your running
routine and icing and elevating the affected knee. An over-the-counter nonsteroidal anti-inflammatory
drug (NSAID) may reduce pain and inflammation, but can sometimes interfere with GI function,
exacerbate fluid imbalance, and contribute to short-term liver dysfunction in long distance runners. Use
NSAIDs on a regular basis only under the guidance of your doctor.
If you don't notice any improvement in knee pain in a week or so, see an orthopedic professional. You
should call your doctor immediately if your pain is so severe that you can't bear weight on your knee,
have marked swelling, or develop a fever.
(Plancher Orthopaedics & Sports Medicine, PLLC, New York, NY, www.plancherortho.com;
Orthopaedic Foundation for Active Lifestyles, Cos Cob, CT, www.ofals.org; Running & FitNews, Vol.
23, No. 1, pp. 1, 5)
Knee Pain: Three While They Run
As a companion piece to Leaving Knee Pain Behind, here we explore three common knee injuries
associated with running, along with their various treatment options.
Patellofemoral pain syndrome. This condition, also known as runner's knee, occurs when the patella
moves improperly and is characterized by pain at the front of the knee, behind or underneath the
kneecap. The pain may be in one knee or in both, and generally gets worse when you run, go up or down
stairs, or sit with your knee bent for a long time (as you do when you're watching a movie or driving a
car).
In most cases, runners can beat PFPS by taking a break from training, putting ice on the knee after
exercising and, if necessary, following a physical therapy program that includes strengthening the
9
surrounding muscles and making them more flexible. Taping the knee or using shoe inserts, or orthotics,
can also be helpful.
Tendon injury. By far the most common tendon injury in runners is iliotibial band syndrome, or ITBS,
which strikes many long distance runners—as well as cyclists, tennis players, and other athletes—who
put active, long-term stress on their legs. The iliotibial tendon runs along the outside of the upper leg,
from hip to knee. In runners with alignment problems, such as overpronation (in which the ankle rolls
too far inward with every step), the tendon will rub against the knee joint, causing inflammation and
pain.
ITBS is characterized by pain on the outside of the knee (or hip) that typically starts a few miles into a
run. Once it starts, the pain will continue and may even get worse as you keep going and will often feel
worse if you run downhill. The discomfort will often go away if you stop running and begin to walk
slowly, a phenomenon that has led many runners to try to "run through" the pain. To treat ITBS, cut
back on the intensity and volume of your training and use ice (and possibly NSAIDs) to reduce
inflammation. You may also perform the classic ITB stretch: crossing the legs in a standing position,
lean toward the hip of the front-crossed leg, and bend with opposite arm raised and curved overhead.
The stretch works best performed against a wall or tree for support.
Osteoarthritis. This is a wear-and-tear condition that occurs when the cartilage in your knee
deteriorates. It usually develops gradually and is characterized by pain and swelling when you run, and
stiffness, especially in the morning and after you've been active.
If your doctor determines that you have osteoarthritis, you'll probably be told to use NSAIDs to manage
the pain and inflammation. In some cases, you may be given injections of corticosteroid medications,
hyaluronic acid substitutes, or the nutritional supplements glucosamine and chondroitin sulphate. The
jury is out on the effectiveness of these latter two treatments, partially due to the lack of dosage and
potency regulations in the supplements industry. For more information, see FitNews Nov/Dec 2006.
(Health After 50, The Johns Hopkins Medical Letter, 2006, Vol. 18, No. 5, pp. 1-2; Plancher
Orthopaedics & Sports Medicine, PLLC, New York, NY, www.plancherortho.com; Orthopaedic
Foundation for Active Lifestyles, Cos Cob, CT, www.ofals.org)
Variations on a Theme: Plantar Stretch Redux
In the Jun/Jul/Aug issue of FitNews, we discussed a study published last summer in The Journal of Bone
and Joint Surgery that validates the efficacy of a stretch that works on the plantar fascia directly. After
eight weeks, the plantar fascia stretch group felt less pain and could perform more activities than the
Achilles stretch group. Even more significantly, when the study ended all 82 study participants were
taught the plantar fascia stretch. Two years later, 66 of these original patients were re-examined, and 94
percent reported feeling either less pain than they had before the study, or no pain at all, with only 30
percent having even undergone further treatment with a physician or physical therapist.
The stretch is performed as follows:
1. From a sitting position, cross the foot to be stretched over your other leg so that your foot rests on top
of your knee.
2. Holding the base of the toes in your hand, pull the toes back toward the shin. (To clarify, this would
mean pulling the toes up away from the ground if you were standing.)
10
3. As you feel a stretch in the bottom of your foot, touch it with your other hand to check that the plantar
fascia is tense under the skin.
4. To perform this stretch as in the study, do it 10 times, three times daily.
Podiatrist and FitNews editorial board member Paul Langer, DPM, has a few additional
recommendations to add:
I had seen the study as well and have been recommending it to my patients for the last few
months. The stretch makes sense since it is known that the plantar fascia becomes thicker and
less elastic as the inflammation persists. The stretch is relatively easy to do, which always helps
with patient compliance.
A variation of this stretch involves gently massaging the fascia while it is being stretched. As
with any stretch, I always advise my patients not to stretch to the point of discomfort and to
avoid stretching if it clearly makes their symptoms worse.
For my running patients with persistent plantar fasciitis, I also often recommend a boot-type
splint for stretching the fascia. There are studies showing effectiveness of the night splint which
stretches the plantar fascia when sleeping.
(J. Bone Joint Surg., 2006, Vol. 88, No. 8, pp. 1775-1781)
Book Review:
Marathon Woman by Kathrine Switzer
by Don Fraser, past president, ARA
If you have not read Kathrine's book, you should rush right out and get a copy and read it cover to cover.
This is “our” book, a story of how running changed Kathrine's life and the lives of millions of women
(and men), all around the world. Kathrine, as you may or may not know, was on the board of the original
National Jogging Association during the time I was president. For several reasons we changed the name
to the American Running and Fitness Association to reflect the change in our membership. A few years
ago the Board of Directors changed the name again to the American Running Association.
Yes—Kathrine is one of us…
Kathrine's story is one that is repeated over and over again with all of us who embrace running as a way
to better physical and mental health. The wonderful part about Marathon Woman is that Kathrine shares
her personal journey, one of passion and commitment. She gives us insights into her own motivation for
wanting to run the Boston Marathon and how she trained for and then went out and proved to the world
that women could in fact run 26 miles and 385 yards and live to tell their story.
Her experience of being attacked at the beginning of that 1967 Boston Marathon by Jock Stemple, the
race co-director, is now firmly embedded in running legend and well documented in her book, with
some great historical photos.
Having opened the door to long distance running for women, Kathrine continued her training, and that
paid off again with her winning the New York City Marathon in l974 with a personal best of 2:5l.
Success as an acknowledged world class runner then opened another door for her and that was with
Avon. Kathrine was hired to set up and run the first Avon Women's Marathon in Atlanta, GA, in 1978.
11
With Avon's support Kathrine then created running opportunities for women all around the globe from
the United States and South America to Europe, Asia and Africa. Some of Kathrine's tales of how lives
were changed by simply being able to run in an organized race will touch your heart. The Avon running
program helped pave the way to the inclusion of the women's marathon as an official Olympic event in
l984. Joan Benoit won that first gold medal and was an encouragement to many more women to make
running a part of their lives.
I hope every member of the American Running Association will read Marathon Woman and experience
first hand her exciting personal journey. I can guarantee you Marathon Woman will motivate you to be
the best you can possible be while at the same time giving you tips on how to do this without injury, or
“turning off” the non-runners in your life, both family and friends.
Interpreting Medical Findings with Caution
A drug, carefully tested by its manufacturer and approved by the FDA, went on the market in the not so
distant past. People began to report side effects, and so an independent researcher decided to conduct his
own study. He put half of the subjects on the drug and half on placebo. This randomized, double-blind,
placebo-controlled study then reported a dismaying number of serious side effects, including 15% of the
subjects contracting eye problems and 8% going blind. The Institutional Review Board halted the study,
statistical analysis confirmed the rates of these side effects, and the study—which concluded that the
drug was harmful and should be avoided—was published in a peer-reviewed medical journal.
A Case Study
The study in question was published in Biol. Psychiatry in 1993, and the drug it denounced was
aspartame, the widely used sugar substitute. Meanwhile, the FDA, the European Food Safety Authority,
and a recent review of all the other published literature found this drug to be safe. So was this one study
enough to change the verdict on aspartame, was it the beginning of a new series of dissenting data, or
was it deeply flawed? The answer is that it was deeply flawed.
The author’s admitted bias against aspartame, which was based on past observations that many of his
depressed patients reported headaches from the drug, set off the study on the wrong foot immediately. It
compared a group of depressed patients to a group of non-depressed controls, each randomly assigned to
a placebo capsule or a capsule containing the aspartame equivalent to 10-12 cans of diet soda daily.
Designed as a crossover study, the subjects took one pill daily for seven days, three days of nothing (the
“washout period”), then the other pill daily for another seven days. The non-depressed controls were
volunteers who worked in the same institution as the study author, which raises the possibility that they
may have known of, or even shared, his bias.
What’s more, the “15% of subjects” with eye problems turned out to be two people, and the “8% of
subjects” who went blind was a single person. There were only 13 subjects in the entire study. The blind
subject turns out to have suffered a retinal detachment, causing blindness in one eye, while he was
taking the placebo. He alone was half of the 15%, with the other being one subject with a
subconjunctival hemorrhage—a common, painless and harmless condition in which the eye develops a
tiny spot from a bit of blood leaking out under the surface of the white of the eye. It can be thought of as
an eye bruise, and often occurs spontaneously and for no apparent reason. It had never been associated
with taking aspartame before, and in fact was not listed on the symptom checklist given the patients
during the study.
12
This is called mining the data. When your hypothesis doesn’t pan out, you go back in and look at what
other rash conclusions you can draw from the specific occurrences during the study. Concluding that
taking aspartame causes eye problems with this data is no different from concluding it causes hiccups
because one of your subjects contracted them during the study. In the case of the placebo group’s subject
with a retinal detachment, the author blamed a delayed reaction to aspartame, as the subject was in the
aspartame-first group. But he had taken his last dose of aspartame six days earlier, and the author-chosen
washout period was only three days. If the author is suggesting that delayed reactions to aspartame
might occur after twice the length of his designated washout period, he is in fact changing midway
through what it is he purports to be testing. The study was not designed to determine whether aspartame
could cause delayed reactions. The author obviously didn’t think that, or he would have made the
washout period much longer. Blaming everything on aspartame whether it occurs in the aspartame group
or the placebo group collapses the idea of a meaningful control group: there would be no way to falsify
the hypothesis. There are myriad other problems with this study, from variances in medications among
the depressed to the fact that they threw partial data from two subjects into the statistical analysis before
the study was terminated (only 11 subjects completed the protocol).
How to Spot Bad Science
The first line of defense when you hear of a new study’s findings is to ask who disagrees with it and
why. And any legitimate conclusion will have many studies buttressing it. Patients who believe
aspartame gives them headaches have been tested in double-blind studies before, and they don’t get
headaches when they don’t know they’re getting aspartame. The five non-depressed volunteers in the
aspartame study didn’t get headaches either. Three had believed prior to the testing that the drug would,
but four of the five reported headaches while taking the placebo. Only one headache occurred on
aspartame. Are we to conclude that not taking aspartame is four times as likely to cause headaches as
taking aspartame? Of course not.
Listed below are seven indicators that a scientific claim lies well outside the bounds of rational scientific
discourse. They come from Robert L. Park, PhD, who published them in the Chronicle of Higher
Education in 2003. Park wishes us to note that these are only warning signs; even a claim with several of
the signs could be legitimate.
1. The discoverer pitches the claim directly to the media.
The integrity of science rests on the willingness of scientists to expose new ideas and findings to the
scrutiny of other scientists. Thus, scientists expect their colleagues to reveal new findings to them
initially. An attempt to bypass peer review by taking a new result directly to the media, and thence to the
public, suggests that the work is unlikely to stand up to close examination by other scientists.
2. The discoverer says that a powerful establishment is trying to suppress his or her work.
The idea is that the establishment will presumably stop at nothing to suppress discoveries that might
shift the balance of wealth and power in society. Often, the discoverer describes mainstream science as
part of a larger conspiracy that includes industry and government.
3. The scientific effect involved is always at the very limit of detection.
Alas, there is never a clear photograph of a flying saucer, or the Loch Ness monster. All scientific
measurements must contend with some level of background noise or statistical fluctuation. But if the
signal-to-noise ratio cannot be improved, even in principle, the effect is probably not real and the work
is not science.
13
4. Evidence for a discovery is anecdotal.
If modern science has learned anything in the past century, it is to distrust anecdotal evidence. Because
anecdotes have a very strong emotional impact, they serve to keep superstitious beliefs alive in an age of
science. The most important discovery of modern medicine is not vaccines or antibiotics, it is the
randomized double-blind test, by means of which we know what works and what doesn't. Contrary to
the saying, "data" is not the plural of "anecdote."
5. The discoverer says a belief is credible because it has endured for centuries.
There is a persistent myth that hundreds or even thousands of years ago, long before anyone knew that
blood circulates throughout the body, or that germs cause disease, our ancestors possessed miraculous
remedies that modern science cannot understand. Much of what is termed "alternative medicine" is part
of that myth.
6. The discoverer has worked in isolation.
The image of a lone genius who struggles in secrecy in an attic laboratory and ends up making a
revolutionary breakthrough is a staple of Hollywood's science-fiction films, but it is hard to find
examples in real life. Scientific breakthroughs nowadays are almost always syntheses of the work of
many scientists.
7. The discoverer must propose new laws of nature to explain an observation.
A new law of nature, invoked to explain some extraordinary result, must not conflict with what is
already known. If we must change existing laws of nature or propose new laws to account for an
observation, it is almost certainly wrong.
Recent Controversy
But even among the best designed studies and clinical trials there exists conflicting evidence and ways
to interpret data. In 1985, the Nurses’ Health Study run out of the Harvard Medical School and the
Harvard School of Public Health reported that women taking estrogen had only a third as many heart
attacks as women who had never taken the drug. This appeared to confirm the belief that women were
protected from heart attacks until they passed through menopause and that it was estrogen that bestowed
that protection, and this became the basis of the therapeutic wisdom for the next 17 years.
Faith in the protective powers of estrogen evaporated in July 2002, when a large clinical trial, the
Women’s Health Initiative, concluded that HRT constituted a potential health risk for all
postmenopausal women. While it might protect them against osteoporosis and perhaps colorectal cancer,
these benefits would be outweighed by increased risks of heart disease, stroke, blood clots, and breast
cancer. But in June, The New England Journal of Medicine reported that HRT may indeed protect
women against heart disease if they begin taking it during menopause, but it is still decidedly deleterious
for those women who begin later in life.
The catch with observational studies like the Nurses’ Health Study, no matter how well designed and
how many tens of thousands of subjects they might include, is that they have a fundamental limitation.
They can distinguish associations between two events—that women who take HRT have less heart
disease, for instance, than women who don’t. But they cannot inherently determine causation—the
conclusion that one event causes the other; that HRT protects against heart disease. As a result,
observational studies can only provide what researchers call hypothesis-generating evidence—what a
defense attorney would call circumstantial evidence.
14
Testing these hypotheses in any definitive way requires a randomized-controlled trial—an experiment,
not an observational study—and these clinical trials typically provide the flop to the flip-flop rhythm of
medical wisdom.
Even the Nurses’ Health Study, one of the biggest and best of these studies, cannot be used to reliably
test small-to-moderate risks or benefits. Proponents of the value of these studies for telling us how to
prevent common diseases—including the epidemiologists who do them, and physicians, nutritionists and
public-health authorities who use their findings to argue for or against the health benefits of a particular
regimen—will argue that they are never relying on any single study. Instead, they base their ultimate
judgments on the “totality of the data,” which includes all the observational evidence, any existing
clinical trials and any laboratory work that might provide a biological mechanism to explain the
observations.
What to Believe?
So how should we respond the next time we’re asked to believe that an association implies a cause and
effect, that some medication or some facet of our diet or lifestyle is either killing us or making us
healthier? We can fall back on several guiding principles.
One is to assume that the first report of an association is incorrect or meaningless, no matter how big
that association might be. After all, it’s the first claim in any scientific endeavor that is most likely to be
wrong. Only after that report is made public will the authors have the opportunity to be informed by
their peers of all the many ways that they might have simply misinterpreted what they saw. The
regrettable reality, of course, is that it’s this first report that is most newsworthy. So be skeptical.
If the association appears consistently in study after study, population after population, but is small—in
the range of tens of a percent—then doubt it. For the individual, such small associations, even if real,
will have only minor effects or no effect on overall health or risk of disease. They can have enormous
public-health implications, but they’re also small enough to be treated with suspicion until a clinical trial
demonstrates their validity.
If the association involves some aspect of human behavior, which is, of course, the case with the great
majority of the epidemiology that attracts our attention, then question its validity. If taking a pill, eating
a diet or living in proximity to some potentially noxious aspect of the environment is associated with a
particular risk of disease, then other factors of socioeconomic status, education, medical care and the
whole gamut of healthy-user effects are as well. These will make the association, for all practical
purposes, impossible to interpret reliably.
For more information on verifying media claims, see Cutting Through the Haze of Health Marketing
Claims in this issue.
REFERENCES:
Skeptic, 2007, Vol. 13, No. 3, pp. 59-63;
“Do We Really Know What Makes Us Healthy?” by Gary Taubes, New York Times, September 16,
2007, http://www.nytimes.com/2007/09/16/magazine/16epidemiology-t.html?pagewanted=1&_r=1;
“The Seven Warning Signs of Bogus Science,” by Robert L. Park, PhD, Chronicle of Higher
Education, January 31, 2003, http://chronicle.com/subscribe/login?url=/weekly/v49/i21/21b02001.htm
15
What is the True Value of Buying “Organic” Foods?
The term "organic foods" refers to the methods used to produce the foods rather than to the
characteristics of the food themselves. The most common concept of "organically grown" food was
articulated in 1972 by Robert Rodale, editor of Organic Gardening and Farming magazine, at a public
hearing:
“Food grown without pesticides; grown without artificial fertilizers; grown in soil whose humus content
is increased by the additions of organic matter, grown in soil whose mineral content is increased by the
application of natural mineral fertilizers; has not been treated with preservatives, hormones, antibiotics,
etc. ”
In 1980, a team of scientists appointed by the USDA concluded that there was no universally accepted
definition of "organic farming." The USDA began to develop an official definition. The original
proposed rules, from 1997, applied to all types of agricultural products and all aspects of their
production and handling, ranging from soil fertility management to the packaging and labeling of the
final product. The proposal included a national list of approved synthetic substances, labeling
requirements, enforcement provisions, and rules for importing equivalent products.
Organic farming and handling was defined as “a system that is designed and managed to produce
agricultural products by…using, where possible, cultural, biological and mechanical methods, as
opposed to using substances, to fulfill any specific function within the system so as to: maintain longterm soil fertility; increase soil biological activity; ensure effective pest management; recycle wastes to
return nutrients to the land; provide attentive care for farm animals; and handle the agricultural products
without the use of extraneous synthetic additives or processing in accordance with the Act and the
regulations in this part.”
While organically approved weed and pest control methods included crop rotation, hand cultivation,
mulching, soil enrichment, and beneficial predators and microorganisms, the USDA indicated that if
these methods were not sufficient, various (non-cytotoxic) listed chemicals could be used. The proposal
did not call for monitoring specific indicators of soil and water quality.
For raising animals, antibiotics would not be permitted as growth stimulants but would be permitted to
counter infections. The rules permitted up to 20% of animal feed to be obtained from non-organic
sources. This was done because some nutrients are not always available organically. Irradiation, which
can reduce or eliminate certain pests, kill disease-causing bacteria, and prolong food shelf-life, would be
permitted during processing. Genetic engineering would also be permissible.
The USDA received more than 270,000 comments on the proposed rules. The vast majority of the
objections pertain to the provisions that permitted irradiation, genetic engineering, and the use of sewage
sludge as fertilizer. The final regulations, published in December 2002, eliminated these three
provisions.
The organic rules are intended to address production methods rather than the physical qualities of the
products themselves. So are we getting what we pay for, when we pay more for organic?
Many consumers who pay more for organic believe that the foods themselves are more nutritious, safer,
and tastier. But the USDA proposal itself noted that, "No distinctions should be made between
16
organically and non-organically produced products in terms of quality, appearance, or safety." In other
words, no claim should be made that the foods themselves are better—or even different.
Organic foods are not more nutritious. Think of it this way: If essential nutrients are missing from the
soil, the plant will not grow. If plants grow, that means the essential nutrients are present. Experiments
conducted for many years have found no difference in the nutrient content of organically grown crops
and those grown under standard agricultural conditions.
Many "organic" proponents suggest that their foods are safer because they have lower levels of pesticide
residues. However, the pesticide levels in our food supply are not high. In some situations, pesticides
even reduce health risks by preventing the growth of harmful organisms, including molds that produce
toxic substances. To protect consumers, the FDA sets tolerance levels in foods and conducts frequent
"market basket" studies wherein foods from regions throughout the United States are purchased and
analyzed. Its 1997 tests found that about 60% of fruits and vegetables had no detectable pesticides and
only about 1.2% of domestic and 1.6% of imported foods had violative levels. Its annual Total Diet
Study has always found that America's dietary intakes are well within international and Environmental
Protection Agency standards.
Manfred Kroger, PhD, Professor of Food Science at The Pennsylvania State University, puts it this way:
“Scientific agriculture has provided Americans with the safest and most abundant food supply in the
world. Agricultural chemicals are needed to maintain this supply. The risk from pesticide residue, if any,
is minuscule, is not worth worrying about, and does not warrant paying higher prices.”
"Organically grown" foods are not inherently tastier than conventionally grown foods. Taste is
influenced by freshness, which may depend on how far the products must be shipped from farmer to
consumer. Tastiness has a lot to do with how long a fruit is allowed to hang and ripen before picking.
Therefore locally grown foods are tastier because they endure shorter shipping distances (which affect
the moment in a food’s growth at which it must be picked), and not because of organic practices.
Many buyers of "organic" foods believe that the extra money they pay will ultimately benefit the
environment by encouraging more farmers to use "organic" methods. But doing this cannot have much
effect because "organic" agriculture is too inefficient to meet the world's food needs. Moreover, the
dividing line between organic and conventional agriculture is not sharp because various practices are not
restricted to one or the other. For example, "organic" farmers tend not to use pesticides, but faced with
threatened loss of crops, they may change their mind—yet can still consider their farms organic.
(Adapted from “‘Organic’ Foods: Certification Does Not Protect Consumers,” by Stephen Barrett, MD,
Quackwatch, Inc., July 17, 2006, www.quackwatch.org/01QuackeryRelatedTopics/organic.html)
ADDITIONAL REFERENCES:
USDA Agricultural Research Service, Resource Economics Division, Information bulletin No. 770, June
2001.
Data: Organic production. USDA Economic Research Service, Oct 18, 2002.
USDA Study Team on Organic Farming. Report and Recommendations on Organic Farming. USDA,
July 1980.
National Organic Program; Proposed Rule. Federal Register 62:65850-65967, 1997.
17
National Organic Program: Final rule. Federal Register 65:80547-80684, 2000. (Dec 21, 2000)
Newsome R. Organically grown foods: A scientific status summary by the Institute of Food
Technologists' expert panel on food safety and nutrition. Food Technology 44(12):123-130, 1990.
FDA Center for Food Safety and Applied Nutrition. Pesticide Program: Residue Monitoring 1999,
August 2000.
Organic produce. Consumer Reports 63(1):12-18, 1998.
Organic food standards and labels: The facts. USDA Web site, accessed Oct 21, 2002.
Boume D, Prescott J. A comparison of the nutritional value, sensory qualities, and food safety of
organically and conventionally produced foods. Food Science and Nutrition 42:1-34, 2002.
THE CLINIC
Fibroma or Ganglion Cyst on the Bottom of the Foot?
I have a pea-sized lump on the bottom of the arch of my left foot, which my doctor believes may be a
ganglion cyst in the plantar fascia. It swells to a larger size after I walk or run on it. I’ve had it for about
six weeks, and it’s tender to the touch; it gets irritated and painful when I run or take long walks on it.
I’ve tried conservative treatments like ice, stretching, a night splint, and I’m in the process of getting
new orthotics. My doctor is now considering cortisone injections or surgery. I’ve been a regular runner
for over 20 years and a marathoner for the past 10. I’ve been told that ganglion cysts often recur, and I
am very troubled by the thought that I may not be able to run consistently again, or for long distances.
What are the various treatments and procedures for this injury, and what are the success rates? I would
also like to know what the recovery times are like.
Jamie Linden
Chapel Hill, NC
I’ve been in practice for 15 years, including two years as a foot and ankle surgery resident, and I have
never seen a ganglion on the ligament in the arch. While it is possible, it is very unlikely. What I believe
this is, most likely, is a fibroma. The only treatment is excision and you never perform that unless they
hurt consistently. First, ask your doctor is (s)he was using the term cyst as a term you would understand,
even though it is really a fibroma. If the answer is still a cyst on the ligament, get an MRI to confirm that
it really is a cyst, get it drained, and you may do very well. If it is a fibroma (as I suspect), get your
orthotics modified to fit the lump without pressing into it. Otherwise, leave it alone until it drives you
nuts; surgery is the only way to get rid of it and recurrence is indeed high.
Gene S. Mirkin, DPM, FACFAS
Kensington, MD
I assume from what your physician told you that the growth is not in the skin but under it. Pea sized
lesions in the skin would include things like the common wart. There are a number of treatments for skin
lesions that would not interfere with running. If the growth had to be removed it would not keep you
from running for very long. A lesion under the skin is a little more problematic and is most likely a
plantar fibroma, inclusion cyst, or ganglion cyst. If the lump is under the inside of your arch along the
18
plantar fascia, it probably is a plantar fibroma, the most common lump we see on the bottom of the foot.
It develops as a fibrous little growth and is relatively dense in consistency, whereas a ganglion cyst
develops as a fluid filled sac and is usually softer and more mobile. It comes from the lining of tendons
and joints, and is less likely to be under your arch. The inclusion cyst comes from something foreign
under the skin, usually after a puncture wound. All of the above are not cancerous and have trauma as a
factor in their development.
The fibroma unfortunately may grow and does have a tendency to return. The majority do not return, but
the surgery could sideline you for several weeks. Injection of steroid into the lump is a common and
effective treatment for both the fibroma and ganglion. I would recommend this as the first step. The
injections will often soften the fibroma, or make a fibroma or ganglion shrink. (An inclusion cyst would
require removal. Surgery would be simple and effective.) Surgery for the fibroma or ganglion is usually
effective, and I too would not anticipate it would bring an end to your running career.
Richard A. Bronfman, DPM
Little Rock, AR
A fibroma is the more likely diagnosis, as a fluid-dilled cyst (ganglion) is rarely painful. You ought to
have a diagnostic ultrasound to identify for certain which type of lesion it is, how big it is, and where it
is attached before you can begin to assess treatment options or get discouraged about time before a
return to running. If the groeth is solid and painful, surgical removal is usually very successful and has
minimal disability.
David M. Davidson, DPM
Williamsville, NY
Shoulder Pain During Military Presses
I am a 46-year-old male who has been lifting weights since about the age of 13. As I have gotten older I
have had to reduce the amount of weight I lift, as well as the number of sets, due to pain in my shoulders
while lifting. The pain is usually only present when I do military presses. If I am unable to lift due to
work or other scheduling conflicts, I notice I can lift pain free for a while when I return. I have had one
of my shoulders arthroscoped twice due to a torn rotator cuff from playing softball 15 years ago. I take
glucosamine/chondroitin daily to help my joints. I realize the easy answer is to cease doing this
particular lift. I wonder, is there anything I can do to correct this problem, or barring that, another lift
that will strengthen the same muscle group without stressing this area?
Mark Weiman
Freeport, NY
This sounds like shoulder impingement syndrome. People who raise their arms over their heads, as with
the military press, often irritate their rotator cuff muscles and tendons. The two previous surgeries have
complicated your situation. Even successful surgeries will leave scar tissue in the shoulder joint. There
are several things which should help your condition:
1. Pay strict attention to your posture. Try to keep your shoulders from drooping forward throughout the
day.
2. If you haven’t been doing so already, start performing scapular retraction exercises. Examples include
seated rows and reverse flies.
3. Eliminate movements that aggravate your shoulders.
19
4. For the time being replace the bench press with incline bench or DB incline bench.
5. Do front, lateral, and posterior raises instead of the military press, at least for the time being.
6. Perform shoulder and chest stretches on a daily basis—but only stretch to a point that does not
aggravate your symptoms.
If these measures doe not help over the next six to eight weeks, I suggest scheduling a visit with a sports
medicine specialist. You may need more intensive therapeutic treatment.
Doug Lentz, CSCS
Chambersburg, PA
The rotator cuff muscles provide the stability your shoulder needs to perform the movements created by
the prime movers of the joint. As you engage in a strengthening program that includes shoulder presses,
your larger shoulder muscles become stronger and create a greater imbalance of strength between them
and the rotator cuff muscles. To continue with shoulder presses, you could try altering your range of
motion, the angle at which you press, and your hand position, any one of which may take the burden off
the shoulder that had the surgeries. You can accomplish this using dumbbells instead of a machine,
which has a fixed path of movement. As noted above, a regimen of rotator cuff strengthening exercises
should be added to your program. A visit to an orthopedist would help you both receive a proper
diagnosis and get more details on which exercises to add.
Greg Tymon, MEd, CSCS
East Stroudsburg, PA
Concerning Heart Valve Leakage, Proper Diagnosis is Key
My 76-year-old mother has been running for 25 years with no problems. She has run several marathons,
enjoying national ranking in the top 10 for her age group, and has set several national age records. She
routinely completes long runs of 10 to 15 miles, logging approximately 35 miles a week, and crosstrains
with bicycling and walking. She has been taking a beta blocker for over 20 years to control blood
pressure. About 6 months ago she began feeling tired and winded more easily on her runs. After a series
of tests, her physician switched her to a different beta blocker. After an echocardiogram, she was
diagnosed with leaky valves. Her physician has advised her not to run more than three miles at a time.
She is devastated, as she is a fierce competitor who is in the midst of training for Senior Olympics. She
does not want to compromise her health but still wants to compete at the highest level possible. What
can she do and where can she turn for advice?
Patricia Neubert
Saxonburg, PA
It’s hard to provide you with specific advice without knowing more details of your mother’s medical
history, but I can make some general comments I hope will be useful. Your mother’s symptoms of being
more tired and short of breath are nonspecific; there are a number of entities that can account for these
symptoms. Leaky heart valves can certainly account for these symptoms, but 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).
20
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 your mother has mild to moderate regurgitation of the aortic and/or mitral valve, she should be able to
continue participating in competitive events if her symptoms do not otherwise limit her. However, if she
has moderate to severe regurgitation, she 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.
ACC/AHA General Eligibility Recommendations for Competitive Athletes with Cardiovascular
Abnormalities: http://content.onlinejacc.org/cgi/content/full/45/8/1318
ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease:
http://content.onlinejacc.org/cgi/content/full/48/3/e1
Todd Miller, MD
Rochester, MN
Editor’s note: Also see Marathoning with Mitral Valve Prolapse in this issue.
THE BACK PAGE
Honoring a Running Hero
One of the legends in our midst was surprised with a unique honor on September 13th. Geoff Hollister
served on the Board of American Running (ARA) for upwards of 8 years. In the fall of 2006, Geoff
stepped down to enjoy his retirement time and complete his autobiography and a tale on the building of
a company, Nike. For this drizzly September day, Geoff was lured back to the Nike campus under the
pretense of helping his wife file some medical forms, to a special evening amongst friends and
associates. That night, Geoff was honored with the first Nike Lifetime Achievement award. No one is
more deserving. He is one of our heroes. Not just because he was my partner in pushing the limits on
new endeavors at ARA, but because he fought for the best interests of running in America. He truly
cares about runners. Geoff has vision and dares to explore paths less traveled. At Nike, Geoff started
building a brand. He created images, designed logos, created shoes, manned the first ever retail store for
Nike under its initial banner name, Blue Ribbon Sports. He invented grass roots marketing, not with
some textbook but by finding ways to help runners and help build a company. Geoff Hollister has made
the running experience in America better for all of us. He still cares about the runner who goes out for
high school cross country because he is too skinny to play football with his bigger friends. He smiles at
that same runner who years later dons a Duck uniform and is swallowed up in the world of cross
country. He also is the same guy who honors those pioneers who preceded him in this sport. On that
day and again today, we acknowledge and salute our American Running Hero------ Geoff Hollister.
We “enjoy the run” because of the impact of people like him.
Commentary: No dishonor for sitting one out
What do marathoners fear most: rain, wind, or heat? Two marathons in 2007 offered the worst of
nature’s elements on race day. The mid-April 2007 nor’easter that hit New England on April 15th and
21
16th almost closed the world’s longest running marathon. Intense heat on October 6th did not initially
close down the Chicago Marathon, yet some 4 hours after the gun went off in Chicago, the race director
gave the order to close the course. What lessons did runners, race directors, emergency preparedness
workers and municipal government leaders learn in both cities? Did each marathon’s staff feel like they
just dodged or survived the worst that nature and weather can throw at them on event day? What did
they learn?
Each race and city had common planning timelines. The huge coastal storm had been forecast for over 5
days. It was just a matter of when it would hit and when the worst of the storm would head northeast to
the Maritimes. The heat wave of October was visible on national maps for 5 days. The Midwest was
warned of rising temperatures as the week wore on. Temperatures were forecast to hit close to 90
degrees.
So what happened? In Boston’s case, the storm track put most of the dangerously heavy rains a bit
west. Boston only had 3-4 inches overnight and early on race day. Parts of New Jersey and western
Connecticut had 6-8 inches of rain and severe flooding. Runners were briefed to bring running gear to
deal with rain and wind. Email blasts focused on how to deal with hypothermia while running. Buses
to take shelter along the course were pre-staged. The start area had additional buses as well. In
Chicago, hydration instructions were emailed to runners. Staff purchased and moved in thousands of
extra cups. Additional Water was ordered to be placed at all water points.
Heat is worse. Many of us can survive rain and wind, but heat withers most of us. Believe me, heat is
worse. You cannot see heat, but your head and body let you know how bad it can be. In a large crowd,
heat can cause people to get agitated and panic. So when a race plans an extra 5-6 cups per person for
water, it still has not addressed the issue of cooling the runners. People want to be cooled down. They
are cooking. Hydration is an issue, but heat exhaustion demands cooling. Runners in Chicago wanted
to cool down and the quickest method was to take cups from water stops and pour them on their heads.
The city opened fire hydrants but it some cases they were located off the path and runners missed them.
Wind would have helped, but giant mobile turbines are not the solution for a calm day.
What should be done to prepare for future mega-sized marathons in the future? One solution is to
establish guidelines for race participation based on wet bulb temperatures. A chart can be developed to
plot expected marathon finish time (i.e., time on the course) with wet bulb temperature. Shaded areas
can indicate when runners should opt to sit out and not run if wet bulb temperatures are forecast to be in
a dangerous zone for runners out on the course for a longer or slower time. Race Directors can also
examine the number of runners registered for their events. Can Chicago and New York put an end to
their escalating race registrations? Is 30,000 starters a reasonable limit vice 35,000 to 40.000 starters?
Each runner has to take responsibility on race day. Know your limits and know when to sit one out.
There is no shame or dishonor for that decision.
RUN BOSTON with AMAA is OPEN
The “Run Boston with AMAA” program has been signing up physicians and allied health professionals
since October 10th. This year we opened up a new option for runners: fundraising for the American
Running Association youth fitness campaign, “One-on-One, Walk & Run”. We have tools in place for
online fundraising. You can also collect checks from friends, associates and businesses. We require an
initial $500 nonrefundable deposit. You are required to raise an additional $1000. Of course, we
welcome any AMAA runner who can do as well as our superstar last year, Marques Williams. Marques
22
raised a total of $3300 for AMAA and the ARA youth fitness Walk-Run programs. Email Dave Watt
(embed the email address in my name: [email protected] ) if you are interested.
Battle of the Potomac XC Championship set for November 17th
Invitations are going out to the best boys and girls running high school cross country in Virginia,
Maryland and the District of Columbia. The 5K double loop course at Smokey Glen Farm will be the
scene once again for the ultimate showdown between the states separated by the Potomac River. The
barbecue chicken and vegetarian chili will be served to the hungry runners after the competition is
settled on the rolling hills of Smokey Glen. Runners get to join forces with rivals and even race sideby-side with others that they have never faced in a cross country race. Thanks to support from Nike’s
Chairman, ARA is proud to produce this high level cross country battle. We showcase high school
cross country as a platform for our push to get more boys and girls active in running. The purity and
simplicity of cross country can lift kids’ spirits and motivate them to greatness both as a student and
runner. Come join us that day to celebrate high school cross country. Event information can be found
at www.battlexc.com
Enjoy the Run.
--Dave Watt
Executive Director
23