THE CLINIC

Slow Down and Skip the Surgery?

I was recently diagnosed with osteochondritis dissecans (OCD) in my right knee. My doctor explained that this is essentially a piece of bone that has separated from the end of the bone. He recommends I have osteochondral allograft transplant surgery (OATS). I have already had meniscus surgery on this knee, about a year and a half ago. I'm wondering what the best course of action is at this point. I've been running for 22 years (I'm 52), and I can still jog slowly on a treadmill.

Paul L. Blake
Lake Arrowhead, CA

In order to make an assessment I’d have to see your MRI as well as an A/P longstanding view of both lower extremities to determine the size of the OCD defect, your weight-bearing alignment, and associated intraarticular knee disease. My experience with allograft osteochondral grafting has been very encouraging. Results, at least in the short term, are excellent.

Rob Meislin, MD
New York, NY

There are many issues with osteochondritis, and the OATS procedure brings more into play. I assume that if allograft is anticipated there must be large OCD lesions, otherwise autograft tissue might be preferable. I would probably avoid surgery until you do not have other options. Patella-centering braces, NSAIDs, quadriceps strengthening exercises, and crosstraining would all likely be helpful. I would avoid stairs, hills, and the like and never train to excess. Some patients use injections of viscous material like Synvics.

In the right circumstances OATS is a good procedure. However, if the lesion is small with intact articular cartilage, the bone scan normal, and your symptoms minor, then the real value of the procedure is less evident.

Larry D. Hull, MD
Centralia, WA

Slumped Form Can Overload the Calves

I am a 62-year-old male who has been running for over 40 years, and over the past two years I have been experiencing calf strain, mostly on the left side. I had to cancel a half-marathon last week due to this. I'm running around 20 to 25 miles a week and I also work with a trainer three days a week; I lift weights, do Pilates, and stretch. I wear orthotics, work with a sports doctor who does Active Release, and change my shoes at 200 miles—nothing works. I'm fine for a few months and then out on a simple run, suddenly the calf starts to go. What should I try next?
 
Russell Mendes
Fairfax, VA

It appears you are doing everything appropriately for prevention and wellness. One of the missing puzzle pieces is diagnostic testing for your spine. Often etiology of lower extremity problems can be found in our lower back or lumbar spine. So, I would recommend an MRI of the lumbar spine. If this test fails to provide reasonable cause then dynamic view x-ray (standing lateral, flexion, and extension) should be ordered to rule-out instability.

Brian Kim, MD
Germantown, MD

I have a practice in physical medicine and rehabilitation and I have a keen interest in running injuries and biomechanics. I have seen your problem before. I would ask you to consider a couple of different angles given your age and perhaps your running style. I am sure you have been through the usual suggestions for calf cramping and calf strain.

Possibility #1: I agree with the notion that this may be coming from your back. You are 62 years old and in a typical age group to have a back that does not move like it once did. Do you have pain with sitting or transitions from sitting? Do you have calf cramps at night or tingling in your toes at times? These, in addition to your frequent strains, may be the result of nerve compression occurring in your lower back. This may be present even if you have an MRI of your back that does not support this hypothesis.

Often posture that does not support extension of the spine can contribute to functional narrowing of the outlets of nerve roots from the back. These supply the muscles of your legs. If they are not putting out optimal current under high demand, the muscles may be unable to support that demand. The result is recurrent strain.

Try this exercise: lay on your stomach, feet dangling off the edge of a bed or mat. Place your hands in a position as if you were going to do a push-up. Arch your head backward (up), then your upper back, then your mid-back, and finally your lower back. Your arms should be fully extended. Ideally your pelvis would stay flat on the mat or bed, but it may lift some. Try to do most of the work with your arms and let your back passively extend. Exhale at the end of the extension and let your belly sag downward, then return in reverse sequence to the mat. You may be quite stiff at first. Try doing a set of ten of these several times per day. Also, whenever you sit, place a towel roll or pad in the small of your back, especially in the car. Even if this does not solve your calf problem, doing the press-ups two times per day is a great preventive exercise for your back. If it seems to make your back hurt or creates other symptoms, stop doing them and see a specialist to help modify the exercise.

Possibility #2: What pace do you run? If it is slower than 9 minutes per mile or if you tend to develop slumped posture, you may be overloading your calf muscles differently than you think. When you land and load your foot and leg most of the weight bearing should be up in your hip, particularly by the time your foot is flat on the ground. This posture will allow you to load your hip and proceed to hip extension as you toe off and drive forward. This is where your stride length and your power come from. If you tend to sink into your knee when you land on your foot such that you have a bent knee and your hip is sitting back behind your knee, you will not load your hip properly and most of your body weight will remain loaded in your lower leg and calf.

When this occurs over and over again it can cause eccentric fatigue in your calf and result in recurrent strains. The solution is to make sure your gluteal muscles are strong and that they are loaded properly when your foot hits the ground. Simply said, practice running tall, as if there is a string tied to your chest pulling your upward. This assumes your gluteals are strong. If they are not, you will need to strengthen them first.

You also may want to work on the eccentric strength of your calf muscles. Stand on a low step with your heels hanging off the edge, using a handhold to remain steady. Raise up on both toes so your heels rise off the step. Next, lift one foot off the step so you are supported only on one foot. Slowly lower your heel below the edge of the step to a five count. Repeat this in a set of 15 reps once per day for each calf. You may not be able to do 15 right away, so work up to it and keep the repetitions clean and in good form. This is great therapy for your Achilles tendon as well.

John Cianca, MD
Houston, TX

Battling Chronic Tendon Injury

I was injured doing yoga over 10 years ago, and I have never gotten over the injury. In yoga it is referred to as “sit bone” pain, but I believe it is essentially a high hamstring injury. I am 54 years old, weigh 112 lbs, and am 5 feet 6 inches. I have been a runner since 1972 and had never had hamstring issues until I combined yoga and running. I have practiced Ashtanga yoga for over 11 years.

I have rested, crosstrained, etc. I am able to run, but not at the intensity or duration I once did and during yoga I have to be very careful when doing anything involving the hamstrings, which in yoga is almost every asana. For running, it means no hills and no interval training. I have gone from 6:30 mile pace to 8:00 mile pace.
 
There have been times when even walking was difficult, and sitting at length (especially in a car) was very painful. Also, at the height of the pain, I could not even do 10 lbs on the curl machine.
 
My new yoga teacher has indicated it may involve the sacroiliac joint and the pelvis being "locked." I’m interested to know your thoughts on this and would really appreciate any suggestions to help me move beyond this injury.
 
Andrea Maracelli
Teaneck, NJ

While high hamstring tendinopathy is most commonly seen in runners, it can occur with other activities. Runners tend to develop this problem after years of running. Tendinopathy describes chronic injury to the tendon as opposed to an acute strain. As a result, stride length will decrease due to a loss of flexibility. Strength deficits will also be present. Single leg exercises to address the strength and flexibility deficits are essential to recover from this problem; stopping the offending activities may be a necessary component of the recovery process. Running through the problem will result in exactly what you are describing: a significant decrease in speed.

The "sit bones" (otherwise known as the ischial tuberosities) are on the bottom rim of each side of the pelvis. The majority of the hamstring tendons originate here. Sitting on a hard surface or in the bucket seat of a car will put pressure on this site, causing pain.

The pelvic bones attach to the sacrum, creating the sacroiliac (SI) joints. Any abnormality in the lower back and pelvis will impact other structures in the area. Chronically irritated proximal hamstring tendons may cause irritation of the SI joints. Irritation of the sciatic nerve and hip flexors may occur in conjunction with hamstring tendinopathy. It is also possible an alignment issue in your pelvis or back was the cause of the hamstring problem. Each step that you take is the result of a chain of events; a problem with one link affects the entire chain.

You should seek evaluation by a sports medicine specialist to assess alignment, mobility, strength and flexibility. You may discuss treatments in addition to exercises, such as platelet rich plasma (PRP) injections. Recovery will be a slow process, especially since the problem has been present for more than a decade. Hang in there with the therapy and you will likely note improvement in your symptoms.
 
Cathy Fieseler, MD
Tyler, TX

Without actually examining you I believe this pain could be caused from small tears in your hamstring or connected tendons. Since your hamstring attaches via tendon tissue, it is possible that the tears have occurred at the junction of the tendon and the hamstring muscle. Sometimes during yoga, participants will overstretch the hamstring causing these small tears. This can be the source of your pain.

If the pain is a result of performing yoga exercises on a firm mat, it is possible that the pain is caused by a bruising. In either case, pain while sitting for a prolonged period in a chair or in a car can be bothersome. This injury will also likely bother you when running, especially on an incline.

I would recommend that you perform higher repetition (15 to 20 reps) leg curls with low resistance. The first intent of these exercises is to stretch the hamstrings and glutes and increase blood flow to these working muscles. The second goal is to increase the strength in these muscles.

Gradually increase the resistance you are using until it is challenging to perform 10 to 15 repetitions in your leg curl exercise. If you experience any pain during either exercise, it is likely that it will be experienced when the muscles are in a stretched position, so pause in a stretched position for two seconds. Let any pain be an indicator that you have stretched sufficiently for that particular repetition. Use your pain to let you know when you have stretched far enough—never try to continue stretching through the pain.

You can place warm, moist heat on your hamstring/buttock area prior to working out to promote blood flow to the areas. Daily contrasting applications of heat before (20 minutes) and ice after (20 to 30 minutes) workouts will help to promote recovery.

When you feel that you are ready to return to running, you should begin on a flat surface and at a comfortable speed. And whenever you perform any exercise or work in a standing or seated position, try to maintain a slight bend at your knees, as this will reduce stress on your hamstrings and connected tendons.

John Comereski, MD
Ithaca, NY

Try Glucose Testing Over Months, Not Just Days

I'm diabetic, 62 years old, 4' 10", and weigh 95 lbs. For three years without medication I’ve been able to consistently keep my morning blood sugar readings below 110. I've noticed after high-intensity tennis or running, though, that my blood sugar count is often in the 200 range. An hour or so later, the level is back down to around 120.

My tennis games are very competitive, and I play four or five times a week. Am I harming my body? In addition to tennis, I try to speedwalk or jog 20 miles a week, and I've noticed my blood sugar level does not spike on days when I just speedwalk. By comparison, my last run was a 5K at 9:15 mile pace, and my blood sugar level was 240 ten minutes after the race. My diet consists mainly of vegetables, oil and protein.

Cynthia Chacon
New Paltz, NY

I emphatically urge you to continue your exercise regimen—the benefits, both physical and psychological, are just too great to give up. That said, please know that it is very common for diabetics to progress over time from managing their disease with diet and exercise, then to taking one or more oral medications, and finally to insulin.

It's good that you test regularly. I would keep your doctor informed about your blood glucose response to the vigorous workouts, as he/she may one day feel the need to prescribe medication to help you manage; this is not a bad thing. You should continue your workouts. Your body's response to them is not unusual, and may be related to catecholamine release. This is a stress hormone that causes the liver to produce glucose. You seem to follow a low-carb diet. Your age at diagnosis suggests that you may have overt type 2 diabetes, which is well controlled with diet and exercise. Remember, however, that diabetes can be a progressive disease and so medications may become necessary down the line.

Kevin Foley, MS
Dayton, OH

Exercise typically lowers blood sugar level in type 2 diabetics during the event and for one to two days following, which is one reason why exercise is recommended for diabetics. Therefore, I suspect you are not as well controlled as you think you are. Check your glycohemoglobin with your doctor. This is a measure of long-term blood glucose control. It is reflective of the last three months of blood sugar levels, and more meaningful than individual blood sugars. I think you may need some type of once-a-day medicine that will make you more sensitive to the insulin your body makes. Another consideration is how much glucose loading you are doing in the meals before (and during) exercise. On a side note, I recommend having a stress test or heart scan, since diabetes is a major risk factor for coronary artery disease, which is often asymptomatic.

Peter Mendel, MD
Woodbridge, VA

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