Take Hypertension Medicine Before Running?

I have been taking 25 mg of Atelnolol and 12.5 mg of Hydrochlorothiazide to control my blood pressure. I started this medication about one year ago. My blood pressure is usually 125/70 when I am on the medications. I am currently training for a marathon and take these medications after my morning run. Is this the right time to take them? Or should I take them before I run?

Stephen Hornbek
Beaumont, TX

The most important issue concerning treatment of hypertension is whether or not you take the medication at all—which you are doing. All other issues, such as when you take the medication, are much less important.

That said, these medications are generally prescribed so that their maximal effectiveness occurs when a person’s blood pressure is highest. As a result, most people take their blood pressure medication first thing in the morning so that the greatest effect will occur during daytime hours, when they are most active. In your case, it might make sense to take your medication an hour or so before you run since your blood pressure is likely to be higher during your training. However, my reasons for suggesting this are more theoretical than proven fact, so if taking your medication before your run would be inconvenient, I don’t see any real reason to change.

Todd Miller, MD
Rochester, MN

It’s important to have a proper potassium and magnesium balance before you run, which can be reduced with the diuretic. Keep this in mind if you take it beforehand. In addition, it is important that you stay well hydrated both during and after the run to avoid dehydration and low blood pressure.

The Atenolol has a long half-life and may provide blood pressure control for nearly 24 hours. If you don’t take it before you run, you may get more out of training because your heart rate may be less “blocked” by the medication. However, this also may cause your blood pressure to be too high on your runs. Since you are training for a marathon, I would advise an exercise test to assess blood pressure control under aerobic stress.

Lloyd Lense, MD
Old Field, NY

ACE inhibitors may not adversely affect exercise performance at all or in the same way that a Beta blocker like Atenolol does, which would allow you to take the medication without regard for your training. Perhaps you could revisit your doctor and see if a change in hypertension medicine is possible.

Melvin Williams, PhD
Norfolk, VA

With Leaky Heart Valves, Which and How Severe?

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?

Mary Bistricean
Evansville, IN

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).

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.

Todd Miller, MD
Rochester, MN

A Second Opinion Before Surgery

I am a 137-lb, 5’ 4” female and I have had two arthroscopic knee surgeries to resolve a torn meniscus and frayed cartilage and bone chips resulting from a fall five years ago. The first surgery entailed drilling a hole in my femur to help blood supply rebuild the damage to my knee. I was consequently onone knee for more than eight weeks and suffered overuse injury to that knee.

I racewalk, bike and rollerblade currently, having been told never to run again. I have been diagnosed with a shifted kneecap in the originally injured knee, and my orthopedic surgeon wants to do major surgery to repair it. Is this really necessary? I have read a lot about similar problems being corrected through exercise. I should add that there is evidence of osteoarthritis as a result of the injury and my age (52). I have been a runner only since I was 24 and wonder is it really the case that I may never run again? Also, is surgery the only answer for the current patella abnormality?

Rena Bourinara
Forest Hills, NY

There are a few problems here working in tandem that are hard to deal with and present a challenge for any orthopedist: a sprinter with hamstring tears, and a distance runner with wear and tear changes to not one knee but both now. 

I recommend a second opinion, if you have not already sought this out, and then perhaps even additional opinions. In general, we try to avoid surgery until there is no other solution. Knee rehab exercises should be used seriously for three to six months before considering a surgical solution. I would look at whether a new MRI might be helpful here. Patella tracking problems can be nasty and take considerable experience on the part of the physician and surgeon. Try the use of a patella centering brace, and also strengthen your quadriceps before you try anything else. It is possible you will run again, but I would not expect the cure to be easy. Try to make maximal use of crosstraining, and always remember that there is life after running and joy to be found in a variety of activities.

Larry Hull, MD
Centralia, WA

Keep in mind that racewalking and biking are also notorious for producing patellofemoral pain. If you go for the surgery, your recovery time would be one year to 18 months. A proper flexibility program can often result in avoiding surgery. To a large extent this depends on the amount of space left between your kneecap and femur. This is called a “sunrise view” x-ray. It’s also useful to determine via x-ray criteria how severe your osteoarthritis is. There is a continuum from mild to severe. Surgery will not improve your ability to run, and even after a year and a half recovery it is important to use a cushioned shoe with orthotics and start on grass only. Most patellofemoral problems are caused by a tightness or contracture in the thigh muscle and iliotibial band. I have had seen senior runners who have taken tai chi or yoga and over about six months increased their flexibility to the point where they were pain free and running.

Robert C. Erickson, MD
Canton, OH

“Hamstring Tendonitis” Doesn’t Address Cause

I’m 37 and small framed at 99 lbs, 5’ 1”, with chronic pain in the back of my left thigh for several months. It started when I was training for a marathon, even though I was following a very conservative run-walk program. I was originally diagnosed with hamstring tendonitis. I quite running for about three weeks and went through several weeks of physical therapy, but the pain would resume almost immediately, even when increasing my mileage very gradually. Nothing showed up on an MRI of my left leg.

I only run about three times a week, 20 to 30 miles, and so I don’t feel this is an overuse injury. I have difficulty believing I have tendonitis. The pain is often most noticeable on days when I’m not doing any activity, for example when I stand up at work after sitting all day. I’ve been running for years and always increase my mileage and/or speed gradually, and have never before had problems with my left leg.

Over the last few months, I’ve begun to have tailbone pain, particularly after running (and rarely during). My regular physician gave me a basic exam and some anti-inflammatories for this. I’m a bit at a loss as to who to see next—another orthopedist, or perhaps a chiropractor? I really would like to get to the bottom of this problem, and not suffer through more trial and error.

Courtney Clark
Florence, AL

I see the type of injury you have frequently and treatment can be elusive if you just focus on the symptoms. The cause is probably not your hamstring, but how you run and the cumulative effects of that gait pattern. This is ultimately the source of the overload, and the ensuing symptoms. You may, for example, have pelvic dysfunction. I also can’t rule out lumbar pathology as a source for your thigh pain.

You may have tendonitis but the treatment must be directed at treating the reason the tendonitis arose, and not just the symptoms that declare themselves. If the muscles of your pelvis and trunk are not working well enough to stabilize your pelvis during running, your hamstring or adductors may become overloaded as they try to keep you upright and moving somewhat efficiently.

You should probably see a physical medicine specialist, a.k.a., a physiatrist. We tend to look at things more broadly and with a mind toward function. I think you could benefit from a gait analysis and a musculoskeletal exam. In the meantime, work on hip abductor (gluteus medius) strength. Using a cable column, stand on one leg and pull the cable away from your side with the other leg from the ankle. Repeat on the other side. Do side-lying leg lifts, as well as squats with your buttocks back and loaded as if you were going to sit down. Also, reduce your running to an amount you can tolerate.

John Cianca, MD
Houston, TX

It sounds like you may need an MRI of your lower back, not your left leg. Often a lower back or sciatic issue will yield symptoms like this, including the hamstring pain manifesting after inactivity, and of course the recent tailbone pain. As noted above, anti-inflammatories address the symptom, not the problem.

I would strongly consider a lower back flexibility program, over about three months before you look for results. It may take six months to work. Once you feel better, continue treating your back or the condition will return in as little as six weeks. The simplest program is to sit on the edge of a chair and bend your head down between your legs. Do this for 10 seconds, five to six times a day. Another option is to purchase a lumbar elastic belt with dual Velcro adjustments for about $24. Try running in it and see if the pain is slightly less. Just be wary of overtightening or you won’t be able to breathe properly. A sports therapist can give you a comprehensive lower back stretching program, during a session in which the doctor coaches you on exercise form and gives you things you can do at home.

Robert C. Erickson, MD
Canton, OH

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