Sports Medicine: Keeping Runners on Track Webcast August 29, 2011 Mark A. Harrast, M.D. Gwen Scott Christy Noel Hurley.

Transcription

1 Sports Medicine: Keeping Runners on Track Webcast August 29, 2011 Mark A. Harrast, M.D. Gwen Scott Christy Noel Hurley Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion your own doctor, that s how you ll get care that s most appropriate for you. Introduction Long-distance running, which is a passionate ritual for so many people, can sometimes take a toll on the body, for sure, but with the right equipment, training and post injury rehabilitation runners can work with a sports medicine team to stay on track. Coming up, a sports medicine physician and a physical therapist will explain their approaches, plus we'll meet a patient, a long-distance runner, who will share her own experience coping with injuries, getting help and succeeding. It's all next on Patient Power. Hello, and welcome to Patient Power sponsored by UW Medicine Health System. I'm Andrew Schorr. Well, we're going to talk about sports medicine with an emphasis on running. That's near and dear to my heart. I still jog a little, although in my advanced age of 60 years old my saying is start slow and taper off. But when I was younger I did 8 marathons and a whole bunch of half marathons and 10 Ks. My son is in college. He runs competitively, he runs distance, and with that can go injuries. Sometimes it's just a little pain or a little tweak, but sometimes it's more serious, and you worry and you wonder when should you seek help. And if you do seek help can it really help and still allow you to meet your goals. Well, we're going to talk about that in this program. Christy s Story I'd like you to meet Christy Noel Hurley, who is a distance runner. She's 41 years old. She's been running for about 8 years, run a whole bunch of half marathons and 10 Ks, and you're going to hear the story of the marathon she ran. Going back to about 2005, I know, Christy, you had an injury. What happened? How did it happen? I was training for my first half marathon, and I really wasn't educated about shoes and eating and resting and stretching. I was just following my training program and going for it, and I experienced some pain in my shin, and I went to see my doctor about it, who is a runner, which is why I chose him, and he diagnosed me with having stress fractures in my left shin. 1

2 Now, that was leading up to the Seattle half marathon, which you wanted to run. You got help there because I know you were diagnosed with shin splints, worked on your diet, swimming, changed your shoes. It worked out, didn't it? It did. I completed my first half marathon in an hour and 50 minutes. So many people that run half marathons then aspire to marathons, it's just a little longer, right, twice as long, and that makes a big difference, I think you and I know. So what happened as you were getting ready to train for the Seattle Rock 'n' Roll Marathon in 2011? What happened? I was on a group run just for fun in the dark, and I rolled my left ankle. That sounds painful. It was. And devastating. So devastating in that you then didn't know what was next. Would you be able to train for the marathon? That's correct. I had already registered. I already had it in my head that I was going to train, you know, train hard for it, and, you know, the worst for me was just knowing that I did have an injury where I just couldn't run at all. Right. And for someone who is a runner that's like that's like the keys to depression. That is difficult. Also you had a goal in running the Seattle Rock 'n' Roll Marathon. You wanted a qualifying time for sort of the granddaddy of all marathons, and that's the Boston Marathon, right? So you were very focused on not just running, but running well. That's right. I had a few different goals, but that was my secret stretch goal. So as you told us both earlier for the half marathon and then for the marathon you connected with one of our guests, and that's Dr. Mark Harrast from UWMedicine, who is a runner himself. With this marathon, your hope of running the marathon, did he help once again? 2

3 He sure did. He really did. What sort of things did you do? Well, he was very encouraging. He even sat down and looked at my marathon training program, my first of three that I actually considered. And, you know, just kind of gave me some guidance as to when I should start it given my ankle injury, how I should ease back into it, you know, and just letting me know that it was still possible, that I would just have to alter my training a little bit. And he actually urged you to listen to your body and he eventually helped you get to a less aggressive training program. He did. He did tell me listen to your body, don't push it. You know, take a day off even if your training program says that you're supposed to do a run. And like I said I ended up using three different training programs. Tell us how it worked out, Christy. So is there a happy ending? There's a very happy ending. I did complete the Seattle Rock 'n' Roll Marathon, and I did qualify for the Boston Marathon. So you reached your goal, and with Dr. Harrast and I know you're working with the physical therapy team too did you feel like you had a team relationship and that made a difference? I really did. They were all people who understood, you know, my drive to run, my need to run, and my goals, and they never discouraged me from trying to reach my goals. They just helped me along the way. Sounds like they were not being, if you will Dr. No, they were being Dr. Yes but saying let's look at the approach that's most helpful and healthy for you, given injuries maybe we're trying to rehab you from. Absolutely. And I just responded wonderfully to that kind of advice because nobody, especially a runner, especially someone who has a goal like that wants to hear "no." 3

4 Well, now, let's meet Christy's doctor who has helped her so much, and that's Dr. Mark Harrast, who is a physiatrist by specialty. He's a sports medicine physician. He's also the medical director for the Seattle Marathon. He is a runner himself. Mark, how much do you run? Oh, it varies from day-to-day, but I've been a runner since the age of 11, so that's been a number of years ago, and I still compete in marathons. And how many marathons have you run? Gosh, I think it's now 10 or 11. So when Christy went to you she was going to someone who understood her pain, maybe you'd experienced some yourself, and her goal of wanting to compete. Definitely. Prehabilitation and Avoiding Injuries All right. We're going to talk to a physical therapist who works with you in a minute, Gwen Scott, who is a runner herself and quit accomplished, but first some things for you. So when somebody is thinking of running these distances you have a term prehabilitation. What does that mean? Prehabilitation we kind of coined as preventive rehabilitation. So it's working on, if you want to say it rehabilitating the musculoskeletal system for getting someone to be able to continue to run before they actually have an injury, so kind of idealizing things for them before they get injured. Give me an example. So for example, like a runner very commonly one of the things that Gwen and I see in our office is very common when we evaluate runners is they have side hip muscle weakness, and that's generally because we as runners tend to run forward and back. We don't play side-to-side sports like tennis or soccer. And if you can think about running, running is really a sport of balance, right? You're always on just one leg, and when you're on that one leg and in your running gait you really have to have a stable base support 4

5 from your hip girdle, and if you tend to be weak in your side hip muscles one of your legs may dive in a little bit and you may when you're running and you may injure your knee or your ankle or your back. So one a very quick example that we look at is, you know, hip muscle strength and symmetry and trying to work on the prehab or prehabilitation would be really strengthening those hip girdle muscles so that they don't, you know, they don't get an injury, like knee pain, which is very common in runners. Gwen, let me talk to you for a minute. Now, first of all, how many marathons have you run? I think it's around 11. Now this prehabilitation, so can someone like yourself, sports medicine physical therapist, if somebody comes to you early, is that a good thing? It's always a good thing to come early. When you still have good function and we can actually see how you move when you're not in pain gives us a lot of information. So early is better. Okay. And then what will you give someone exercises, strengthening, stretching? What will you do? Right. It depends on what you find when you evaluate them, so you need to break it down. You need to look at the symmetry, look at the muscle strength like what Mark was talking about with hip strength, core strength, determine if there are weaknesses, and then actually watch the person run. So ideally do a video analysis where you can see what they're doing, so maybe you give strengthening but you might also give some cues for form and technique, things they can actually start to do in real time and might even help strengthen them in the moment and not just with the exercises. And when we talk about form, what you might get away with for two miles or three miles, when you make it 26 miles it gets magnified. That's right. So form becomes really important, and strength becomes very important at that 26 miles. Okay. Mark, so what can someone do? I know when Christy came to you, you said let's try some swimming, and there are deep water exercises and conditioning. And for a lot of 5

6 us who have run, I mean I've run for years, not being out on the trail or the road really bugged me. How do you help people understand that this can keep them in shape? Deep Water Running During Rehabilitation Yeah, so that's a great point. When runners get injured they very commonly have lower limb, lower leg overuse injuries, and when it's an overuse injury it means, you know, you're using it too much, so we sometimes have to really rest them. And it's very difficult for runners sometimes to really not be able to exercise and not be able to run, so deep water running is a really great way to continue to exercise in a running form without actually putting all the weight and weight bearing through. So like my runners with stress fractures or other lower leg or lower limb injuries, you know, I really push deep water running. Now, I have to say and I may have talked to Christy about this it's not the most exciting because you're not outside, you know, seeing scenery. You're in a pool, so it can be quite boring at times, but there has been good research that shows that runners can really maintain their fitness if they regularly deep water run. And meaning fitness like oxygen consumption and VO2 max, which is a test for aerobic fitness. And the way some people don't understand what that means, so then the other thing that I tell patients is there are some studies that show that you can maintain your performance, too, so your 5 K race times can remain the same, if you transition all your land based running into the pool and do it in the deep end of the pool. So it can be a really effective way to stay in shape while you're injured. Another nice thing about it is you can you know, for those high mileage runners, who are really running a lot and every day or six days a week, you can take one day and do that in the pool, and it just lessens your volume on the land and lessens impact forces. So I want to ask you, Gwen, about listening to your body. So you run a lot, and you have a lot of friends who run, and you often know people will run through the pain. When do you say, you know, I have to really get some help? Well, kind of the generic form of wisdom on that is you have a pain, you start to run and the pain goes away. We typically think, well, it's probably okay to keep running. Or you start to run, you have a pain, the pain doesn't really go away but it doesn't really get worse, doesn't alter your gait, probably okay to keep running. But if you have a pain and the pain gets worse and it starts to change the way you're running, changes your form, then it's time to stop and get help. And that's pretty generic. I mean, everyone has to listen. Sometimes your gut will tell you. Going back to what I said it's better to see you early, if it's a recurring theme that every time I get to five miles my knee hurts, it's probably better to see someone about it because it can only just 6

7 improve your performance to address whatever is causing that pain in the first place. Mark, Christy has mentioned that you helped her adjust her marathon training program because you thought it was more aggressive than it needed to be, but, you know, somebody's fiercely competitive and so can less sometimes be more? Oh, for certain. Now, obviously, you know, when you're training for a marathon you have to get the mileage and you have to get the distance in, but a lot of days, a lot of times nowadays people really push too much and just do too much, and that's where we see all these overuse injuries, and that's where, you know, people people keep Gwen and myself in business. So a lot of times less can be more, and being just smarter about your training and, you know, being more focused, taking appropriate rest days and not getting a lot of, quote/unquote, junk mileage in can, you know, really change a training program quite a bit. Nutrition and Diet And what about diet? So Christy has told me, well, you also adjusted her diet, more protein, etc., looking at that? Yeah, so that's a little bit more difficult, and that's very individual, and it really depends on who who the runner and who the patient is. But diet concerns are, you know, important, one, for just performance, you know, to have the right nutrition to be able to sustain, you know, longer endurance runs and that and be able to have the calories that you need to, you know, be able to burn those calories and be able to continue to run longer distances. But then it also comes to, you know, with regard it injury prevention and that, making sure that you have the right amount of calcium and vitamin D in your diet, you know, to help with bone health and prevent the potential for, you know, stress fractures which a lot of runners can be plagued with if they do a lot of mileage. Gwen, Christy was talked about physical therapy, the physician being on a team with her. Is that the way a runner should look at it, that there's a team effort going on there, you shouldn't feel like you're giving yourself over to a medical group and all is lost? Oh, absolutely it should be a team. I mean, I'm constantly telling my patients that almost always, they've walked in the door and told me what's wrong and I just have to help them figure out how to make it better. It always needs to be a dynamic between everyone involved, and it's sometimes massage therapist, physical therapist, doctors, dieticians. So I think you're always going to get a better result when everyone is working together for 7

8 the same goal than maybe conflicting ideas about how things should be done. Mark, we mentioned you're the medical director at the Seattle Marathon and you see people at the medical tent for a variety of reasons. Our listeners don't want to get there. So let's talk about some of the things that have gone wrong and if you could push back the clock things you wish they had done so that they would have never arrived. Yes. I think there are two big things that always worry me that I see at the medical tents at the Seattle Marathon and at various other marathons that I've worked at. And I'll just start off by saying you already mentioned one of the preventive strategies, and it's listening to your body. A lot of people will run marathons and have this goal time in their mind and may not be making it initially and then they try to make it up at the end of the course and push too hard and push through an injury or push through a potentially, you know, medical concern. And then those are the people who end up in the medical tent a lot of the times. One of the to specifically address your question, one of the more common things that's been around for a number of years now, 10 or 15 years we've been seeing this in marathon medical tents, is a problem with over hydration, so really overdrinking, overdrinking fluid on the course. And it can cause something called hyponatremia, which is low blood sodium. And it's kind of an interesting phenomenon which is very different than what people that work in hospitals see when they see sodium issues. It's really came about from people just drinking too much on the course, and very commonly it's beginner marathoners who really don't have a good hydration plan. And it's those that tend to be on the slower side, so those that run the marathon in greater than four hours, so it's more you know, greater than nine minute per mile pace, and one of the reasons for that is that they just happen to be on the course longer so they can drink more, so it's just more time for them to drink. And then the other risk factor would be smaller runners, so runners who are smaller and then can more easily over hydrate so if they drink just a little bit too much because they've got a smaller build they can dilute their blood sodium levels and create this what I called hyponatremia, which can be quite problematic, actually. It can be as benign as just having a little bit of a headache, feeling a little bit of puffiness in your fingers and your rings are a little bit tight, to being potentially much more much more serious and can cause seizures and loss of consciousness, and ultimately even death if it's not really caught early enough. And there have been a few reports in the literature, even in the Boston Marathon a number of years ago, where someone died of overdrinking with low blood sodium. And this is, you know fortunately there has been a lot of talk about this over the years, and when I talk to the marathoners before the Seattle Marathon, you know, we have a little educational session the day before about some medical concerns and just talk about drinking and how much to drink and how much not to drink. 8

9 Is there clue to know when you've had enough and to skip the water stop? It's better to just have a good hydration plan in general, so I mean general guideline would be well, I should say, first off, most marathons have caught on to this and don't really station their water stations more than a mile or less than a mile and a half apart. So if the stations are about a mile and a half apart and you drink one or two cups of, you know, liquid, probably not that big of a deal. It's the people that, you know, walk through each aid station and drink, two, three, four cups, particularly on a hot day where they feel like they need to drink more, that's where people get into problems. And one of the one of the ways to kind of prevent this would be just really listen to your body and drink according to thirst. So don't push fluids if you don't think you need them. And then dump the water on your head. Exactly. Exactly. Stay cool that way. Running Trends Well, I want to move on to another topic. Gwen, my little boy bought these shoes where the toes, you know, sort of on every toe, and I'd even see some kids around my area on the trails run with no shoes, and you talk about mechanics. Where are we in this rage in running? Well, you know, it's not a new rage. People have been running barefoot for a long time. That popular book that was published a couple of years ago by Christopher McDougle probably brought it up more into popularity with people running barefoot. It's funny that you say that you see kids running in them because my impression I've been seeing a lot of middle-aged men wearing them, so I think it's across the board. Lots of people are getting excited about this idea of barefoot running. And there's some great things to be garnished from the idea of barefoot running. It gets you to concentrate on your form. It's a lighter something on the end of your feet which makes running a little easier. It's always going to be easier when you don't have something heavy on the end of your foot. Cheaper, right? No. Those five fingers cost about a hundred dollars. So it's cheaper to go barefoot, but 9

10 it's not necessarily cheaper to buy the sole protectors that people are making. Mark, what about you? What's your vote? You know, the way I look at it, it's like many things in our society, I think it's swinging a bit too far too soon. And what I mean by that is, you know, like you guys mentioned, this is obviously a big rage right now, and it certainly is, like Gwen said, it's been around for a very long time and people are looking back and saying, gosh, maybe we should be doing what our ancestors were doing and running barefoot. Why do we need these really built up shoes? And I think there's some really intriguing research and just what we see in clinic that makes sense about this. But I think it's going a little bit too far because we don't have enough research to really be able to say does barefoot running prevent injury, and I think that's what a lot of people are hoping for and thinking, and we just don't really have the details yet. I mean, in my own practice I've seen a few injuries that look like they come from barefoot running, such as foot stress fractures. In male runners specifically, and those things I don't usually see in male runners are metatarsal or forefoot fractures. Now, on the opposite coin or the opposite side of that I have a lot of plantar fasciitis patients, so patients that have chronic heel pain from overuse that are runners that, you know, really practically cure their symptoms or do really well when they transition to barefoot running or minimalist shoe running, and it's probably because they're strengthening their foot muscles and therefore lessening the stress on their heels. Mark, let me see if I get this right, where we are now is. So Gwen is saying come in early, we work as a team, and Christy was saying I asked her, I said, it sounds like Dr. Harrast is not Dr. No. He wants people to have their running goals and wants to help you get there. So it sounds like there are ways to stay in shape, achieve your goals, but you may need to be make sure you're ready to go in before training and then in training to evaluate whether it's it's the right program for you. And then if there's an injury maybe make some adjustments. Didn't get it right? Yeah, you summarized it really well. Okay. So is there hope for people? So if someone has an injury can you get past it, or do you always have to worry about, that's going to come back. And let me ask Gwen that. Can you make changes so that the injury you had that plagued you in year one is not in year two? You can overcome injuries and address issue as to why you got there in the first place and not have that injury occur again. I think the hard thing is the consistency and kind of 10

11 commitment that it takes to continue to stay strong. Some people feel like, oh, I just did these hip exercises for a while and now I'm running pain free and I'm good to go, I can go back to all my bad habits. But typically we'll always develop these patterns of movement and we'll always need to focus on strengthening. Kind of like what Mark was saying earlier, that running is this very sagital plain motion so we always need to be conscious of strengthening the muscles that control all these other forces through our body. Hey, Mark, I've got one more question for you. I'm almost 61. I ran eight marathons in years past and did a lot of miles and enjoyed that, and I'm sort of getting back into running now particularly because my gym is closed. They're putting in some I've gotten back on the trails, and I'm running. So what about the aging runner, if you will, and I know that people much older than I are running, but are there special things we need to think about? Certainly. You know, I think we all have to realize that as we age our bodies wear down, and that means our muscles and tendons and ligaments can wear a little bit too, just like our joints can, so like with arthritis and cartilage issues. And with that, you know, you just have to alter your training. And that means, you know, if you pick up running again in your 50s or your 60s, you can't, you know, do it like you did it in your 20s and 30s. You know there's much more need for rest, potentially more days off, more time for a warm-up before you start really exercising to get your muscles a little bit more distensible and warmed up. So a lot of like alterations in training that need to be done. And then, you know, a lot of the older runners, and I'm, you know, getting in there as well, we really like you've mentioned many times now, you have to listen to your body and know when it's you know, you don't want to push too far. Gwen, I've got a question about stretching. Do you stretch right off the bat at the beginning, your muscles are cold, or do you wait? And how important is stretching after a run? I think there are probably as many answers to the stretching as there are to whether or not we should be running barefoot or in shoes. It depends is the answer probably that would get me out of that the easiest. Typically we would say stretch after. It's probably better to start your run slow, warm up, maybe walk first and warm up before you run, and then when you're finished is a great time to stretch because that's when your muscles have good blood flow, they're going to be much more supple, and you'll probably get a much more effective stretch. Plus you can stretch out some of that lactic acid and waste products that might have built up during your run if you've really worked them hard. Then there are people and there is research saying that passive stretching might not be good for us at all. So I think it depends. If people like to stretch and they feel good with 11

12 it it's probably better to do it after their run. Closing Comments Mark, any final tips you want to give people when we talk about really trying to run successfully, avoid injuries or get them handled before they're too serious or recover from them. When you put it all together in your head, what do you want people to know? That running if running is an important part of your life there's no reason there's likely no reason that you can't do it as long as you take care of certain things. And that means again we've said it, this is my mantra, and you mentioned from the very beginning, listening to your body and being sure that you're just not doing too much too soon. And when you have an injury or when you feel something is coming on you need to back down and make some decisions about, you know, seeing a healthcare provider potentially or just taking a little bit of time to rest. And, Gwen, so you're out there competing, trying to win races, and you're on teams and all that, but you're on the inside of this field. Any final thoughts you want to leave with the running community on how they can be hopefully in less pain and injury free or at least deal with them successfully? Definitely everything that Mark has said. Listen to your body, address issues early, pay attention to your nutrition and your training. And along the lines of aging, I'm getting up no, I'm not, I'm in my mid 40s, but so I read research articles that are going to support what I want to believe, but the one that I think stands out the most in terms of running and aging is the Stanford study and they've been following runners now for close to 30 years, and they started with runners who were in their 60s. And that research is consistently showing that running is good for us, and that's with older adults that they're studying. And no increased risk of arthritis versus the nonrunners and doing better on IQ tests, fewer health issues. So listen to your body and be smart about it, and you can have a long life of running. Yeah. I'm going out there now. I'm a super advocate for running on trails because you get to use all your different muscles in all sorts of different ways, not the same repetitive stress that you get on the road, so it's great. Gwen Scott, who is a physical therapist with UW Medicine and devoted to sports medicine and helping runners, thank you for being with us. 12

13 Thank you. And Dr. Mark Harrast, who a physiatrist, a runner himself and a physician devoted to helping runners and the medical director of the Seattle Marathon, thanks for being with us. Thank you. We're going to give the last word to Christy Noel Hurley with her advice for our listeners. Christy, we've had our discussion with Dr. Harrast, Gwen, learned about what they can do to help, but really there are people listening who say, hmm, I don't know, I'm either going to push through the pain or maybe I just have to give up. What would you say to them as far as encouraging them to seek a consultation with specialists like this who are really devoted to runners? Well, first I would say don't give up. You have a goal, there's going to be a way to get to that goal, and I think the way to get to that goal is to, you know, seek the help of a professional and, you know, hopefully have a great relationship with that professional where they become like your teammate and your cheerleader and your coach rather than someone who will just tell you, no, you should just give up. Many people would feel like oh, my god I'm just going to get in bed and pull the covers up, it would be such a dark day. Well, I'm glad it didn't work out that way for you. So Boston is in April of Starting to think about it, even at this very early time? You got a visual image of crossing that finish line and, what is it, Heartbreak Hill you've got to run up? That's right. I'm start starting to think about it. I'm hopeful that in the registration process I actually make it in because it's a very complicated registration process even if you do qualify. But, yes. I mean, as a runner you when you commit to something like this or even to a 10 K or a half marathon you have to visualize succeeding. That's part of the training. Well, you can bet that Dr. Harrast and our physical therapist, too, today, Gwen Scott, will all be cheering for you. We wish you all the best, Christy Noel Hurley. Lots of many years of hopefully injury free running, okay? 13

14 Thank you very much. Alright. Lots of good news for runners and the teamwork that can benefit you in helping you with injuries that are going to happen but still reach your goal. Very inspiring for me and I think good news for people who really want to devote themselves to running. I'm Andrew Schorr. Thank you for joining us. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion your own doctor, that s how you ll get care that s most appropriate for you. 14