Sprained ankle while adventure racing

Hi Gary,
I sprained my ankle just over four weeks ago during an adventure race and continued to race for a further 2 hours to finish with my team.

I have not been able to run on the ankle but have been back on the bike quite a bit since then. The ankle is still a little swollen and is tender to walk on first thing in the morning. Does a sprained ankle require any specialist intervention or will it heal just as well without? I guess I am saying “should I get it looked at”

?

Also are there any good exercises that I can employ to aid recovery and strength?
Wayne

Read more!

Cortisone Injections - pain relief at what cost?

Note: This is an update of an earlier article.

Let me present the case of a very fit woman who, by anybody's terms, completely overdid the exercise for a few months towards the end of last year. She developed left ankle pain that would not resolve. She was referred to a sports medicine physician who injected the spot with hydrocortisone. Being a sports physician, he would have been well aware of the risks associated with these injections and would have exercised due care with the procedure.

The relief was immediate and she was able to resume normal activities several days later.

About 6 months later, she developed diffuse ankle joint pain when running. It refused to respond to treatment, including rest. The ankle would throb while sitting. Running out of options, she came to see me.


Her case is quite typical of what I see months after cortisone injections and long after the patient has been declared "cured" of their musculoskeletal pain.



Photo One shows the left ankle appearing to be less meaty in appearance as compared to the right.









Photo Two shows a hollow towards the front margins of the ankle bone



Photo Three shows a marked hollow where there should normally be fat and ligaments

So, what is going on here?

What hydrocortisone does
Hydrocortisone is a means of doing a "chemical exision". In other words, it is a way of removing tissue without the need to cut. The chemical literally dissolves tissue. This is very effective at removing spots of persistent pain - it makes the problem literally disappear!

The problem
While it removes the pain, it invariably leaves the structure weakened. Furthermore, wherever the fluid leaks, tissue is killed off. In this case, healthy tissue - including shock absorbing fat and gristle and protective ligaments were damaged and even disappeared altogether!

It would also appear that some cortisone leaked into the joint itself, causing arthritic changes that now show as diffuse pain throughout the ankle joint, including the other side and general throbbing.

These complications are common. The first instance I can recall was of a running mate who was just on the heels of elite milers like Dixon, Quax and Walker. He developed plantar fasciitis of the foot and had a cortisone injection that fixed the problem. A few months later, he was out for a training run when he felt something snap in his foot. The plantar fascia had completely detached from the heel bone. His foot catastrophically collapsed. When I examined his foot, the arch was absent, he had knee pain due to altered foot mechanics and there was no fatty pad under the skin of his heel - it had been completely dissolved! That was the end of his running career.

Once the tissue is gone, it aint ever coming back.

I have seen plenty of cases of delayed complications. Possibly the most common is cortisone injections to relieve tennis elbow types of pain. This can result in complete avulsion of the wrist extensor muscle where it attaches at the elbow.

In these kinds of cases where there is a delayed complication, the treating doctor may forever remain blissfully unaware and will have chalked the case up as a treatment success.

Sometimes, the cure can be much worse than the ailment itself.

Read more!

Ankle pain in older runners

Gary
I have been running since I was a boy; I won my first school title when I was 10, and since then I have run ever since. In April this year I turned 40, so have been running for 30 years, reasonably consistently.
Whilst I've had my share of reasonably serious injuries (many self-inflicted, but a number being managed as I get older), my biggest concern is after a 1 hour plus run on hard surfaces, my feet and/or ankles just hate it, and I spend the whole run, waiting until it's over. I did a easy 75 min flat run with my mates yesterday, and I just couldn't wait until it was over. In terms of shoes, I wear Asics 2110 at home and work, so a reasonable shoe.
I am actually worried for the first time ever about how this might affect my running. Any suggestions of what I can do? Likely treatment or supplements?
Regards
"B"

Photo: sometimes, foot and ankle problems are easy to spot; more often, the trouble is not so obvious and, unfortunately, there are no single, quick-fix solutions.
___________________________
Gary Moller comments:
Thanks, "B", for consenting for this going onto the web: The problem you describe is one of the most pressing faced by "ageing" runners. If not resolved, the runner may be forced into giving running away and we can't have that happening, can we?

The best approach to dealing with foot and ankle pain is to tackle the problem from several different angles and hope that one, or a combination of the following suggestions have a beneficial effect:

• Run, step and bound barefeet weekly in sand. This is what the great coaches of old, like Percy Cerutty, always had their athletes do as part of their training. When Otago athletes of the 1970's were at their height of national prominence, coaches like Alastair McMurran had regular bounding sessions up the massive sand dunes of the Otago Peninsula (I had the dubious pleasure of doing a couple). This type of training helped develop and maintain strong, flexible feet and ankles. This type of training is all but forgotten nowadays and much to the detriment of runners. This type of training is all the more important as we get into our 40's and older. Joints, muscles and tendons thrive on being flexed and extended through their full range of movement. On the other hand, repetitive and restrictive movement, such as running on pavement is not good for feet and ankle joints.
• Try different shoes and fit semi-orthotic inner soles. Although I prefer Asics myself, an obvious measure is to try a few different makes and models. The change can be remarkable when it comes to ankle pain. I have 4 different pairs that I rotate, including a pair of Asics designed for off-road running. The semi-orthotics I recommend are Formthotics Active which can be purchased here. A measure as simple as an inner sole change can give relief.
• Do your ankle and foot exercises. If your feet tire as a long run progresses, the arches begin to drop, shock absorption diminishes and the outer borders of the ankle joints may be bruised which you may really feel upon getting out of bed the next morning! Here is the link to the E-Pub on the subject. Of course, these do not replace sand dune running!
• Get your leg pulled! Yes, get a strong massage therapist to get stuck into your feet and ankles, working on mobilising all of those tight sinews and joints, including the main ankle joint. Manipulate a child's supple feet and the contrast with a typical runner's feet will shock you. So get into it and don't neglect the sand running which flexes the feet better than any masseur.
• Take Glucosamine, Chondroitin and magnesium daily. Joint food preparations help guard against arthritis and may even help reverse the process. If the feet and calf muscles are tiring prematurely and cramping, this may be partly due to magnesium depletion which is a near universal problem with older runners. If the muscles tire, then the feet cease doing their stability and shock-absorbing work, thus throwing abnormal strain on the structures of the ankles and feet.
• Run off-road. Buy a pair of shoes designed for trail running and do all of the long runs on trails. The soft surface and constant adjusting of foot and ankle placement is what those feet were designed for and they love it! Take care at first: your lack of flexibility and dulled reflexes from all that road running means you need to take care initially not to stumble or trip. The foot and ankle pain may be stirred up initially; but should diminish and disappear as the feet and ankles strengthen and regain flexibility with regular trail running.
• Do cross training. Aqua-Jogging done properly and cycling are my favourites. These enable the ageing runner to continue to develop a huge cardiovascular reserve while sparing muscles and joints that have already given more than a lifetime of faithful service!

(For more about this topic, type "ankle" into the search box to the upper left of this page and search this blog.)

Read more!

The 21 day rule for medical treatments

The 21 day rule
I often come across people including athletes who have been undergoing a form of treatment for months; sometimes longer. It raises the question: "How long should one undergo a course of treatment before calling it quits?" As a general rule of thumb, I recommend applying the "21 day rule".

If you are undergoing any form of treatment or therapy be it physical therapy or medicine, apply the 21 day rule.

If, after 21 days of consistent application of the therapy, there has not been a significant improvement in your condition and at a rate or level above what would normally be expected if things were left up to Mother Nature herself, then you need to review what is being done. Far too often, ineffective therapies are continued with long after when their use should have been critically reviewed, modified or ceased altogether. Progress is often erroneously attributed to the treatment or medicine when it is really just the natural healing processes that should be getting the credit.

Nutritional and lifestyle strategies, including exercise, to improve fitness, healing and health can be extremely subtle in effect. These enhance and support, rather than replace or inhibit normal body physiology. Sometimes no obvious benefit is ever demonstrated by exercise, eating well and supplementing where the need exists, other than looking good and feeling great over the long term. Give these strategies at least 3 months to take effect.

Read more!

Does glucosamine and chondroitin work for runners?

Glucosamine assists the repair of worn or damaged cartilage while chondroitin assists the hydration of cartilage, thus improving shock absorption and reducing wear and risk of injury. Their actions are supported by a growing body of research and the experiences of clinicians, including vets.These substances are best taken with various other nutritional co-factors, including MSM, copper and vitamin C which are beneficial to joint health. Many formulations, including the two listed here have these additional nutrients in them.

The benefits may be noticed within days, but it is usual to undergo a course of supplementation taking the maximum dose daily over a 3 month period before easing off. As with most nutritional strategies to maintain health and to be inury free, the effects are subtle to the point of being impossible to measure. In answer to queries about benefits for connective tissue other than joints: the answer is "Yes". they are beneficial for tendons and even the skin, nails and hair.



Should a runner take them? My recommendation is to do so if you are over the age of 35, or have had a history of joint problems or injury, a family history of arthritis, if you are in a job that is stressful on your joints or if you are doing particularly heavy training or intense competition - or all of these!

Read more!

Chronic Pain Syndromes

"Dear Gary,
I was sorry I missed hearing you speak... I have had polymyalgia for 2 years and am on Prednisone 11mg daily, but it is barely keeping it under control and I will probably have to increase it. Can you please send some information that might help?"
"M"
__________________________
Gary Moller comments:
I have been dealing with chronic pain syndromes for the last 30 years. These conditions present in various forms including polymyalgia, RSD, RSI and fibromyalgia.

These are characterised by disabling painful and inflamed muscles, tendons and joints that do not readily resolve despite medications, remedial exercise or rest. An episode of ill health or an injury might have been the precurser for the condition that may continues on with a life of its own.

These aliments are more common in women than men. There would appear to be an association in some cases with menopause. There are no known cures as such - just mangement and it runs its course, be that months or even years. I have been taking a renewed interest in these conditions, partly because I have had so many inquiries about them lately.

It is still early days; but I am highly suspiscious of two factors at play which, if properly dealt with, may asssist a healthy resolution.

Vitamin D deficiency
Vitamin D has a growing list of health benefits, and "D" deficiency is associated with muscle and joint pain as well as immune system dysfunction. The people commonly afflicted by fibromyalgia and similar conditions tend to be office workers, women in their 50's and others who may have gone for long periods of deprivation of sunlight. An episode of illness, including hospitalisation sees to that.

Recent investigations of clients with "myalgic" conditions have returned positive blood test results for serious vitamin D deficiency. All that must be seen now is what happens over a year or so with deliberate boosting of vitamin D levels.

Mineral and vitamin Deficiencies
Muscles and circulation do not function properly if minerals, especially magnesium and calcium are deficient. From work with athletes, I am aware of how common this health problem is and how easily a person can become deficient. Poor circulation, fluctuating blood pressure, aching muscles and joints eventuate. This may be accentuated by deficiencies in vitamins, the B Group in particular. It is too early to tell, but supplemetning with vitamins and minerals along with boositing vitamin D levels may be of benefit as would adding omega 3 oils like Evening primrose, flax seed or fish oil to the diet.



Menopause
If the sufferer is a woman 50 years old or so, strategies to alleviate menopausal symptoms is an obvious action.

What about exercise?
Exercise, other than gentle and preferably done in a pool is of little benefit if the body's anabolic processes are faulty. Attention to diet, vitamin D levels and some supplementation will eventually have the body in a position to build its strength and vitality in response to exercise.

With all good things, these natural approaches require time and patience - several months or more for any lasting benefits to show. These "healthy measures" are complementary to medical treatment and which one should continue and be subject to ongoing review.

Prednisone and other medicines
Should you keep taking Predisone or any other prescribed medicines for chronic pain syndromes? The answer is "Yes!" if you already are. Some medicines like Prednisone, especially if you have been taking a lot of it for more than a few months, should never be stopped suddenly. If you are wanting to reduce your medication, get started by getting on a regime of vitamin and mineral supplementation, get your vitamin D levels measured via your doctor, take measures to boost your "D" if needed and give these time to take effect - then talk to your doctor about the possibility of a gradual cessation.

Discuss with your doctor before starting.

Read more!

Cortisone Injections - pain relief at what cost? Followup

Here is some feedback from the runner with the ankle pain that I referred to in my earlier article.

“I'm great... I've been back runnning for about 7 weeks...

“When you told me to start back , you will probably remember I still had the throbbing scenario - after that the ankle was giving me pain in the first few weeks of running. I've crept up slowly in kms and have had to go at a slower pace than I want ... but it's now not throbbing at all and only the very rare day do I feel familiar scary pains here and there.in the ankle... if that happens I get as much rest before the next session or swap sessions around.

So to answer your question yes your intervention did work for me, I was going backwards for many months (9 in total ) with the rehab exercises which I reckon were aggravating it more.

Before I ate healthily but now am using protein (just after a session which I never did before), calcium, minerals and flax will keep going and will keep the joint powder going for a good while yet.

Yes looked at the blog, and that is a great article , I hope it helps others make the right decision, all you need is a perceptive experienced advisor.You are the only person that I saw that wanted the entire background to my running habits and history.... and thank you ! “
___________________________

Gary Moller comments:
This very fit woman has made a remarkable return to running training. What she shows is the value of looking at the total person, including her health and exercise history, training programme, diet, physique and biomechanics - and let's not underplay the role of her determination to get back into running!

When attempting to understand how such injuries develop in the first place, it is essential to understand the constant balancing act that is going on inside the body between anabolism and catabolism. Refer to this E-Book here and read the sections about anabolism and catabolism. If an athlete is in a state of chronic catabolism, there is no way that any kind of medical treatment is going to "cure" her.

Although this dedicated runner has made a quick and remarkable recovery, healing and repair should be regarded as a slow and gradual process, taking several months, if not years to fully run their course. Too much therapy is on the basis of a 1/2 dozen visits and, if there is no cure, then more drastic action is recommended like surgery, or cortisone. Of course, these don't work and can leave the athlete with much worse problems over the longterm.

Central to modifying her training and diet and her doing some special exercises, is the moto "Body, heal thyself". This is a phrase all health professionals should constantly mutter away to themselves as a constant reminder that they never heal or cure - it is the patient's body that does that!
______________________________________

If you have a chronic injury or illness that you are getting nowhere with fast, and if you are in Wellington, I run a private clinic in the central city. Get hold of me to arrange a consultation - I really do enjoy the challenge of working with people like you!

Read more!