THE CLINIC

Carb Intake Disagrees with My Stomach

I get nauseous whenever I try to take gels or food during long-distance events. I cramp up and sometimes vomit, usually at around the three-hour mark. I’m an experienced female runner who competes in Ironman competitions and other endurance events. I would love to know how to solve this problem, because not being able to ingest additional carbs at critical points in the race is affecting my performance.

Myra Collins
Atlanta, GA

The fact that these symptoms occur well into these extended events suggests that dehydration or electrolyte imbalance is affecting peristalsis. When peristalsis, the muscle contractions that propel food along the digestive tract, is interrupted, nausea and vomiting can result. There is a normal reduction of blood flow to the digestive tract during exercise, but this occurs early and remains so throughout the exercise, so it would not be the cause of a problem this late in the event.

You should pre-hydrate with sports drink containing sodium, and continue to hydrate throughout the exercise period. Peristalsis is very sensitive to salt and water imbalance in the intestinal tract. Many runners restrict their nutrient intake late in the race to fluid-only. Be sure to experiment on long training runs with various foods—your intestinal tract needs to be trained for an endurance event in the same way your other muscles and organs do.

Dennis D. Daly, MD
Camillus, NY

Home Help for Ankles and Hips

What can I do at home to sooth my arthritic joints? I am looking for self-administered treatments for my ankles and hips in particular. Are there over-the-counter medications, herbal remedies, or hot/cold therapies I can try?

Michael Martinez
Ontario, CA

Though the studies are mixed as to potential benefit, many people swear by glucosamine/chondroitin sulfate, two triple-strength or three double-strength tablets per day. Over-the-counter pain relief medications like capsaicin and ibuprofen can help. You can also try topical salves like Tiger Balm, Ben Gay, or Mobisyl. Heat brings blood to an area and is a vasodilator, so it can help before exercise or activities, while ice acts as a pain reliever by vasoconstricting, and is therefore best used after activities. Ice also offers some pain relief.

There are also homeopathic remedies such as Arnica (in pill or gel form) that can be purchased in health food stores and/or homeopathic pharmacies.

Mark McKeigue, DO
Flossmoor, IL

Although it seems like new treatments for every medical condition seem to appear every week, there are not a great deal of new treatments for osteoarthritis (OA) in the past year or so. My recommendations to patients include:

1. Maximize flexibility and strength. Other joints in the same limb are affected by the loss of motion in an arthritic joint. As muscle strength increases, there is decreased stress on the joints. Although stiffness and pain are usually present when exercise is started, symptoms commonly subside during the course of exercise.

2. Try both heat and ice. Some people get much more relief with one compared to the other; a pattern of heat prior to activities and ice afterwards works for many people.

3. Maintain an appropriate weight. Too much weight means greater stress on joints.

4. Appropriate footwear. Shoes should have good support and cushioning.

5. Braces. A simple knee sleeve may provide some improvement in comfort. An unloader brace applies valgus stress to the knee and may be beneficial for someone with medial compartment arthritis.

6. Medications and supplements. The data on supplements is mixed. There was good support for the use of glucosamine, though a meta-analysis study in the New England Journal of Medicine did not demonstrate positive results. I have a number of patients who report improvement in joint pain while taking glucosamine. The form of glucosamine—pill vs. liquid—does not seem to matter, but liquid is much more expensive.

Studies are being performed on chondroitin, ginger, and multiple other supplements. There is some reported improvement in pain with these supplements. NSAIDs are effective for decreasing pain, but chronic use increases the risk of renal or hepatic toxicity. Lab tests should be monitored if NSAIDs are taken on a chronic basis. Acetaminophen plays a role in pain control. Chronic use may cause hepatic toxicity, especially when used in conjunction with alcohol.

7. Injections. Cortisone injections may provide temporary relief from pain (weeks to months) and can be beneficial in ameliorating symptoms. This treatment should be used sparingly, however.

Hyaluronic acid injections (Synvisc, Supartz, Hyalgan) can be quite helpful in decreasing pain. At this time, these are only approved for use in knees, so insurance will not cover this treatment for injection into other joints.

8. Surgery. When pain is severe and other measures have not been working, this is a long-term solution. Prostheses are being improved and have a longer life span.

Cathy Fieseler, MD
Tyler, TX

Hypertension Drug Options for Active People

Since I started taking the drug atenolol to control my hypertension, my running performance has suffered. I’ve run 13 marathons, but now I am fatigued after three miles. I’ve also gained weight, which is probably due to my decreased mileage, but I’ve also heard that weight gain could be a side effect of taking this drug. Is there a substitute medication that does not have these side effects?

Stanley Caple
Marlborough, MA

There are essentially four classes of medications that can be used as first-line agents for the treatment of high blood pressure: beta blockers, calcium channel blockers, diuretics, and angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs). In general any of these classes of medications represents a reasonable choice for the treatment of
hypertension.

A certain agent may have more benefit in an individual depending on additional characteristics of that patient. For instance, beta blockers have additional benefits in patients who also have had a heart attack or heart failure, calcium channel blockers in patients with angina, diuretics in patients with ankle swelling, and ACE inhibitors/ARBs in diabetics.

One agent may also be more effective than another based on patient demographics (age and race). Cost may also influence medication selection (in general generic beta blockers and diuretics are cheaper than calcium channel blockers and ARBs).

Atenolol is a beta blocker. It can cause the side effects that you mention. Beta blockers generally do not impair performance in people engaged in moderate (leisure) physical activity, but many athletes performing at a higher level find the side effects to be intolerable and to have a negative impact on athletic performance.

From a biochemistry standpoint, beta receptors exist in the heart and blood vessels as well as in other tissues throughout the body. Stimulation of the beta receptors with chemical substances like adrenaline that get released during exercise cause the heart to beat faster and stronger (more forcefully). Beta blockers bind to these beta receptors, thereby partially blocking the effects of adrenaline, resulting in a slower heart rate and less forceful contraction of the heart
muscle. These effects are desirable in someone who has had a heart attack but are undesirable during athletic competition since maximal cardiac performance (and hence athletic performance) depends on the increase in heart rate and increase in contractility of the heart muscle during exercise.

You should never stop any blood pressure medication on your own. This caveat is especially true with beta blockers, since these medications may need to be gradually tapered rather than abruptly terminated when discontinuing. I would suggest that you discuss with your physician the side effects that you have noticed and the possibility of changing from atenolol to a different class of medication. With the large number of blood pressure medications that are currently on the market, it is usually possible to find an effective medication or combination that controls blood pressure adequately with minor or no side effects.

Beta blockers are the class of medication that stand out as being not well tolerated in athletes. The other three classes are pretty much a toss-up. Theoretically athletes might want to avoid diuretics if training/running in hot weather as diuretics could predispose towards dehydration. I would lean towards using an ACE-inhibitor/ARB or calcium channel blocker, especially if you are still doing marathons. The major disadvantage is cost but there are generic ACE-inhibitors and calcium channel blockers on the market, which helps.

Todd Miller MD
Rochester, NY

Itís Not the Surgery, Itís the Findings

Years ago I tore the meniscus in my left knee and it healed okay. I run today at 7:00 pace over six or seven miles, on paved streets, for a total of about 40 miles per week.

However, I just had the same surgery on my right knee. I am 50 years old and for the first time I harbor doubts that I'll be able to continue indefinitely, performing speed work eight months out of the year and generally training and racing as hard as I do. Will I damage my knees further, and can I expect recurring injuries in a few years?

Gunnar Dahl
Northfield, MN

The critical issue isn't whether you've had the surgery, but what the findings were: do you have arthritis? What was the status of the articular cartilage? Based on the answers to these questions, your orthopedic surgeon can make activity recommendations. There is a multitude of low-impact aerobic activities you may try: bicycling, swimming, rowing and cross-country skiing come to mind. But none of that may be necessary if all that arthroscopy revealed was grade one or two chondromalacia, which is a softening of the cartilage.

Klaud Miller, MD
Evanston, IL

It seems like you may be neglecting to cross-train, which is an important aspect of a running regimen that helps make injury less likely. If your surgeon advises that you have a lot of wear and tear on your knee, I urge you to incorporate cross training into your routine. I also would add that as a general principle, we don't wear out so much as rust out. If you don't have substantial knee disease, avoiding running will not be necessary, though after 50 slowing down a bit and easing up on the mileage may be a wise thing to do.

Larry D. Hull, MD
Centralia, WA

Don't let the history of two knee surgeries be a reason for despair. Speak to your orthopedic surgeon and find out the quality of the articular hyaline cartilage on your femoral, tibial, and patellar sides. That's the coating of the bones around the knee. If there are exposed bone patches, you might have to cut back on your running. If the coating is intact, then keep on trucking.

Rob Meislin, MD
New York, NY

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The American Running Association (ARA) and its Clinic Advisory Board disclaims responsibility and shall have no liability for any consequences suffered as a result of your reliance on the information contained in this site. ARA does not endorse specifically any test, treatment, or procedure mentioned on this site.

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