THE CLINIC

Zero Impact Can Still Injure Knees

I am primarily a runner but recently I’ve started biking several times a week. As a runner, I’ve gone over 25 years logging about 15 miles a week without pain or injury—granted, mostly on a treadmill. Still, I was surprised when I recently began to develop pain in my right knee. I’ve always been under the impression that the impact forces due to running were the major culprit of knee pain, and that biking was in fact what a lot of injured runners wind up resorting to permanently after they “retire” from running due to knee pain. The onset of this pain has almost exactly coincided with my new biking habit. It is on the outside of my right knee, and so it feels a lot like iliotibial band syndrome. Can bicycling cause knee injury?
 
Corey Tibbit
West Palm Beach, FL 

It’s important, first off, that you don’t go too long guessing at a diagnosis: If your problem hasn’t resolved after resting for a week or two, find a sports medicine professional for a thorough evaluation. Iliotibial band syndrome (ITBS) is most common among runners, but it can also occur in cyclists. Cycling might also exacerbate an underlying, mild ITBS condition. Whether or not your problem turns out to be ITBS, the first thing you should do is find a professional bike shop and have your bicycle evaluated for fit. If your frame is too big or too small, or your seat adjustment is incorrect for your body, it can increase the stress and strain on both of your knees, hips and back. 

Once you are certain your bike fit is correct, you can minimize strain while riding if you avoid your big ring and stay in your saddle. When climbing hills, try spinning up rather than pushing a bigger gear. You will generate less force and will decrease the compressive load on your ITB at the knee. 

As for recovery and future prevention, avoid running on a cambered surface (this doesn’t apply if you always run on a treadmill). Make sure you are wearing the right running shoes for your foot and running style, without excessive mileage. It is also very important to keep the ITB stretched from the hip to the knee. Stand with your left side about 12 to 18 inches away from a wall or other support, and cross your left foot in front of your right foot. Lean toward the wall, with your right arm straight up, pushing your right hip away, stretching your arm toward the wall, until you feel a stretch from the hip downward. Hold for 30 seconds and repeat on the other side. 

Pain can be minimized with massage (manually or by rolling on your side on a styrofoam roll); icing, stretching and topical anti-inflammatories (ask your pharmacist about these). It can be helpful to strengthen the gluteal muscles, particularly the gluteus medius, which is primarily responsible for abduction (moving the leg laterally away from the body), and is important in controlling pelvic motion. This may, in turn, reduce the tension on the ITB from above. To strengthen hip abduction, while lying on your side with the affected leg up and weight applied to the ankle, slowly lift (abduct) the leg and slowly lower it. 

John Cianca, MD
Houston, TX

Underperforming Thyroid May Not Compromise Racing Goals

About seven years ago, I began taking a hypothyroid medication; the dosage has remained 10 micrograms. I started on Levoxyl but soon switched to the generic brand of levothyroxine, and I take the medication with a low-dose aspirin and, during the summer, Claritin. My internist tests for thyroid-stimulating hormone (TSH) each year. Last June it was 5.084. The year before, it was 5.1.

I began jogging almost three decades ago and got serious about running and entered my first races about three years in. That year I ran a 3:22 first marathon. I am now 63 years old, and my concession to age is running four days a week, with a base of two 4-milers and two 6-milers. I substitute one 4-miler with weekly speedwork when I am training for a race. I also crosstrain once or twice a week. My weight has edged up a little: from about 152 to about 165, but I’m no more than five pounds heavier that I was 10 years ago.
When I turned 40, I ran three sub-3:10 marathons, including Boston. After a decade off, I had no trouble running two sub-3:30 marathons (age 50-54) to qualify for my second Boston Marathon. 

My goal the past two years has been to run a Boston qualifying time of 3:55 (age 60-64), but it has proven elusive. Last year I dropped out of a race after 21 miles, then entered another marathon four weeks later, posting a 4:03:58. In both cases I ran at a comfortable 9:05 pace for 12 miles, then died. The struggle in the 13th mile has become more like what I would not encounter until 16-18 miles in previous decades. 

Could my premature falloff be linked to my hypothyroidism? I’ve always understood the medication is to be used for maintenance and there shouldn’t be a wide swing even for a missed dosage. Might there be a cumulative effect over the weeks of longer runs and hard track workouts that go along with racing prep? 

James Sharma
Anaheim, CA

There are multiple factors which may be affecting your marathon performance. First of all, performance decreases with age. Training will slow the rate of decline, but will not stop it. 

Hypothyroidism can negatively impact performance, though on medications, this should be a minimal/negligible impact. Your TSH is at the upper end of normal limits (a high level is consistent with hypothyroidism); too much thyroid replacement can cause a number of medical problems. Your TSH levels are consistent over time, though levels do need to continue to be monitored. Adjusting the medication dosage so that your TSH is on the low side of normal would probably not have a significant impact on training and could cause side effects. 

I think that you need to look at your training schedule and racing pace. It looks like your fastest miles are at the start of the race; most runners perform best with even or negative splits. Are you using too much energy (for your level of training) early in the race and paying for it in the middle of the race? Possibly incorporating a medium length run at planned marathon pace in your schedule will be helpful; start at 6 miles and gradually increase to 12 miles. This could replace your speedwork. Make sure that there is sufficient recovery between this and your long run. You might also consider working with a coach to tailor a training program to your needs. 

Cathy Fieseler, MD
Tyler, TX

Your TSH is indeed at the upper end of the normal range (at least in most labs), so there is probably room to increase your thyroid replacement slightly (by 12.5 to 25 micrograms), followed by a repeat TSH in three months. If it has not decreased below your lab's lower limit of normal, your replacement dose may be more optimal. 

In addition, though small variations in the amount of active thyroid hormone in each pill are probably not significant, some generic brands of levothyroxine are not considered reliably potent. I would suggest using the brand name Levoxyl for your replacement (it has the most consistent potency data). 

Whether this minor thyroid abnormality is the reason for your relative decline in performance is uncertain, but these small changes are easy to accomplish and will allow you to test whether the thyroid is the culprit.

William M. Simpson, Jr., MD
Charleston, SC

Debilitating Nerve Pain Down the Leg

I am a 160-pound, 58-year-old male who usually averages 15 miles a week at 9 or 10 minute pace. I had also been using weights three days a week to strengthen my upper body—until three months ago, when I started experiencing sciatica-like symptoms down my left leg, with no direct pain in the back. The pain was severe enough to cease both my running and my weight training. I began to make good progress with regular back stretching exercises, acupuncture, muscle relaxants, anti-inflammatories and chiropractic adjustments. I see a sports medicine doctor who oversees these treatments. 

I had reduced my pain considerably in the mornings, with no pain for the rest of the day. I gradually started walking, then walking and running, then running for three miles. I was down to just the anti-inflammatory drug and regular stretching when I had a major setback a month ago, while I was out of town. I was unable to even stand from the terrible pain down my leg. I ran the day before this occurred without any problem. I am back on acupuncture, avoiding the chiropractic, and making progress, though the numbness on the bottom of my left foot continues.
I walk as much as I can, which is only for about 10 minutes. How should I go about starting my weight training and running once the nerve heals? 

Forrest Adams 
Montville, CT

I think your spine is a likely source for your symptoms. Even without back pain, sciatica usually arises from the spinal nerve roots. Some practitioners diagnose piriformis syndrome as a sciatica source when back pain is absent. This is a deep muscle in the buttock that lies over or around the sciatic nerve. The notion is that the nerve gets compressed by this muscle when it is tight, spasmed or externally compressed, such as by a wallet. These scenarios are medically possible, but in reality probably very rare. The problem, if it is truly nerve related, is almost always the spine. 

A combination of degenerative disc bulging and bony joint enlargement compresses an existing spinal nerve root, usually the lowest lumbar or the first sacral nerve. The majority of sciatica resolves. But your case is unique in that you are 58, you want to get back to running and you may not be getting better. I recommend an MRI study of your lumbar spine; recommendations for activity will be in part based on the results. This can also help the chiropractor determine how best to apply his/her skills. 

The initial rehab sounds like it was appropriate. You will have to start from scratch again. When symptoms return like this, you need to see your doctor and work up the problem for a more definitive diagnosis. Generally speaking, return-to-running programs involve starting at a pain-free level and only increasing mileage by 10 percent per week. 

Robert Scott, MD
San Diego, CA

As Summer Approaches, How Much Salt is Too Much?

Recently two of my running partners—who happen to both be very strong athletes—have developed hypertension. This surprises and worries me. I consume an enormous amount of salt, most often in the summer, when I actually crave it. I sweat profusely, but I do have a history of hypertension in the family. My blood pressure is okay right now (120/75), if slightly higher than the 110/60 from 10 years ago.
Without a lot of salt, my training schedule makes me very lethargic. Can my sodium intake be harmful? How often should I check my blood pressure? I am a bit of a type-A personality and have had trouble sleeping, plus hot flashes associated with menopause. I really wish to avoid developing hypertension. 

I am a 53-year-old female with 25 years of running under my belt. I currently run about 35 miles a week, as I’m training for a marathon. I am 5’ 5” and 120 lbs. I run a 5K in 24:30 and a marathon in about 4:15. I do tempo runs, long runs and speedwork. 

Marybeth Holt
Casas Adobes, AZ

With a blood pressure of 120/75 and clearly a salty sweater, you are doing the right thing and should not worry unless you actually develop hypertension. 

Athletes sweating in the summer sun should not abide by the dietary limit established for sedentary adults: 2,300 milligrams of sodium daily. As internist for the Oklahoma Sooners, I have found some OU football players, during two-a-day workouts, to lose five teaspoons of salt a day. Heat cramping and exhaustion result from lack of sodium. Never drink more than you sweat. Overdrinking, even fluids with sodium, can dilute blood sodium. If you gain weight during a long run, drink less next time. 

If you see salt on your skin or clothing or sweat burns your eyes, you may need more salt than most people during a workout in the sun. Foods with lots of sodium include tomato juice, canned soup, pickles, pretzels, and pizza. 

Randy Eichner, MD
Oklahoma City, OK

As noted above, your desire for salt seems like your body’s appropriate response to your exercise regimen. You might obtain a home blood pressure monitor at your local pharmacy and monitor it twice a week. Keep a diary of these readings to be sure you’re on the right dietary track. While excess sodium does carry the risk of hypertension, the dangers of hyponatremia—dangerously low blood sodium—are worth reading up on as well.

Lloyd Lense, MD
Hauppauge, NY

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