Admittedly, I am not a professional writer or master of prose. I am, however, a person that has invested a lifetime pursuing methods of helping injured athletes at all levels achieve their goals and return to optimal performance. Over the past twenty years of working with athletes during adversity, here is what I have learned........we humans are more capable than we believe, we just need a little help to guide us.
The evidence is all around us; elite athletes coming back from life threatening injuries to fully compete again....80 year olds fininshing an Ironman.....amputees taking back control of their lives and returning to competitive sports, etc. etc. etc. Nearly all things are possible, but there are two key ingredients to make the seemingly impossible possible. (1) A complete commitment of the individual to overcome and succed and (2) access to accurate information and resources to allow success.
Commitment is an individual choice, and nothing is possible without total commitment. Commitment is personal and essential. A motivational video or someone selling a program for "guaranteed success" may motivate us to start to tackle a goal, but unless there is complete conviction, success will be short lived if it is even achieved.
Access to accurate information and resources is another matter. The "misinformation" highway that the common recreational or age-group athlete looks to for resources on recovering from injury or improving performance can be a little misleading, many times asking for a blind investment from a company, product, or individual and trusting what they are being told or sold will work. Can most people afford this? I think not. In my position, however, we are able to evaluate and try most avenues being developed to help people achieve their physical goals, particularly when injured. The purpose of this blog is to share information from research and personal experience and make the trip on the "misinformation highway" a very short trip. I hope it will help others dealing with injuries and setbacks guide themselves to achieveing their goals.
Thursday, May 30, 2013
Monday, May 27, 2013
The Insanity of Chronic Sports Injuries Revisited
They say insanity is doing the same thing over and over and expecting
a different result. Simply resting an overuse/chronic injury until it
feels better then
returning to sport only to see the problem arise again is (by
definition) unnecessarily insane. Resting and resolving symptoms won't necessarily correct an injury brought on by mechanical overuse. The repeating stresses that bring on
overuse injuries in an athlete must change, or the same resulting
repeating injury will occur; to think otherwise is plain crazy (pun
intended). When an injury occurs, most athletes are told to treat the
area with some type of physical modality to reduce their symptoms (i.e.
ice, ultrasound, electrical stimulation, etc.), rest, and return to
activity when feeling better. They treat the resulting symptoms instead
of addressing the source of the problem, return to activity, and, at
some point, incur the injury condition again. This is the insanity of
chronic injuries. If you are in this category, there steps to take to
stop the madness........
As athletes at all levels are now training year-round at higher and higher levels to achieve better performance, there is an inevitable accompanying risk of injuries to soft tissues. Muscles, ligaments, tendons, and bones subjected to stresses that exceed their capacities result in injuries. Sometimes this is an acute strain, but more often than not, it is a gradual onset of pain that eventually disrupts workout patterns and routines if not handled correctly and/or rested. Ultimately, overuse injuries are caused by mechanical inefficiencies and/or imbalances of the body. We all have differing areas of mechanical inefficiencies and thus have varying areas of soft tissue overload. This is why two people performing exactly the same workouts might have two different areas of soreness or injury following a workout. It is also why treating or rehabilitating an injury with the same methods for two different people might not yield maximum recovery results for both athletes. Injury treatment regiments and injury rehabilitation programs should be individually constructed for every person, addressing the source of their problem to help reduce their symptoms and developing a specific plan accordingly.
In any soft tissue/overuse type of injury, determining the mechanical causes and developing correction strategies is the biggest challenge for the sports medicine specialist. What causes IT Band Syndrome in one athlete might be different than the cause of the same condition in another. The same holds true for patellar tendonitis, plantar fasciitis, metatarsal stress fractures, SI joint/back pain, etc. Athletes should be leery of a particular technique, product, or method that claims to "cure all of problem X". There is no shortage of products being advertised reporting to be the complete remedy for all sorts of sports related maladies. Pick up any fitness related magazine, and you will find the supposed sure fire cure for whatever sports related injury you might have. Sadly, there are no immediate shortcuts to solving a chronic injury problem. Most of these products can assist in treating the symptoms of injury and get pain to subside in the short term, but long term, the problem will most likely return unless other changes are made. Some products can help to correct the mechanical problems leading to injury, but must be used specific to the injury condition to be effective. It all seems quite confusing and leaves many people with chronic injuries feeling hopelessly helpless.
If you suffer from repeated injuries in particular areas, there are five general rules to follow to guide you to a maximum recovery with smallest chance for repeated injury:
1. Identify a sports medicine professional qualified and experienced in diagnosing mechanical problems and muscular imbalances in athletes and who has a track record of correcting these problems. To help you with this, look for a certified athletic trainer (ATC), sports physical therapist (PT) or physiotherapist with experience in these areas. Ask around for recommendations from higher level athletes, professional sports teams, or major colleges, or seek out professionals who work with athletes at the highest level. They will be most familiar with these correction strategies.
2. Develop an understanding of the injury and it's causes and work with the specialist to develop a plan which corrects the problem's source, not just treating the symptoms. This must include a corrective exercise plan to address the identified mechanical issues which are causing the problem. (If the person you are working with can't do this, you picked the wrong person)
3. With your sports medicine professional, develop a comprehensive corrective exercise plan to address your mechanical inefficiencies and adhere to it religiously! Good sports medicine professionals will help you do this while working around your planned workout schedule. This may include the use of specific devices or therapeutic techniques to help address the underlying mechanical problems that have resulted in injury.
4. Every good corrective exercise program will involve development and coordination of the core muscles during this program. Without a strong core for a solid foundation, other corrective exercises may not be effective in the end. (More on this in an upcoming blog)
5. Be cognizant of your limitations while recovering from the injury, adjust your workouts accordingly until the problem is resolved, then develop a progressive return to specific activity plan taking advantage of your new mechanical corrections. (alternative methods to maintaining your conditioning while injured was the topic of two previous blog posts).
6. Don't be closed minded to the fact that some of your workout choices, athletic gear (shoes, bike, racquet, etc), and workout conditions may be contributing to your problem. Be prepared to make changes in areas within your comfort zone. Athletes who find the right sports medicine professional and trust and adhere to their recommendations typically respond the best.
As promised in the last blog, we will focus on providing information to help guide you through all of the misinformation. The next five blogs will focus on information from the five tips above to arm you with information to win the overuse injury battle and avoid the chronic injury asylum.
Until then, train hard, train safe, and train smart!
As athletes at all levels are now training year-round at higher and higher levels to achieve better performance, there is an inevitable accompanying risk of injuries to soft tissues. Muscles, ligaments, tendons, and bones subjected to stresses that exceed their capacities result in injuries. Sometimes this is an acute strain, but more often than not, it is a gradual onset of pain that eventually disrupts workout patterns and routines if not handled correctly and/or rested. Ultimately, overuse injuries are caused by mechanical inefficiencies and/or imbalances of the body. We all have differing areas of mechanical inefficiencies and thus have varying areas of soft tissue overload. This is why two people performing exactly the same workouts might have two different areas of soreness or injury following a workout. It is also why treating or rehabilitating an injury with the same methods for two different people might not yield maximum recovery results for both athletes. Injury treatment regiments and injury rehabilitation programs should be individually constructed for every person, addressing the source of their problem to help reduce their symptoms and developing a specific plan accordingly.
In any soft tissue/overuse type of injury, determining the mechanical causes and developing correction strategies is the biggest challenge for the sports medicine specialist. What causes IT Band Syndrome in one athlete might be different than the cause of the same condition in another. The same holds true for patellar tendonitis, plantar fasciitis, metatarsal stress fractures, SI joint/back pain, etc. Athletes should be leery of a particular technique, product, or method that claims to "cure all of problem X". There is no shortage of products being advertised reporting to be the complete remedy for all sorts of sports related maladies. Pick up any fitness related magazine, and you will find the supposed sure fire cure for whatever sports related injury you might have. Sadly, there are no immediate shortcuts to solving a chronic injury problem. Most of these products can assist in treating the symptoms of injury and get pain to subside in the short term, but long term, the problem will most likely return unless other changes are made. Some products can help to correct the mechanical problems leading to injury, but must be used specific to the injury condition to be effective. It all seems quite confusing and leaves many people with chronic injuries feeling hopelessly helpless.
If you suffer from repeated injuries in particular areas, there are five general rules to follow to guide you to a maximum recovery with smallest chance for repeated injury:
1. Identify a sports medicine professional qualified and experienced in diagnosing mechanical problems and muscular imbalances in athletes and who has a track record of correcting these problems. To help you with this, look for a certified athletic trainer (ATC), sports physical therapist (PT) or physiotherapist with experience in these areas. Ask around for recommendations from higher level athletes, professional sports teams, or major colleges, or seek out professionals who work with athletes at the highest level. They will be most familiar with these correction strategies.
2. Develop an understanding of the injury and it's causes and work with the specialist to develop a plan which corrects the problem's source, not just treating the symptoms. This must include a corrective exercise plan to address the identified mechanical issues which are causing the problem. (If the person you are working with can't do this, you picked the wrong person)
3. With your sports medicine professional, develop a comprehensive corrective exercise plan to address your mechanical inefficiencies and adhere to it religiously! Good sports medicine professionals will help you do this while working around your planned workout schedule. This may include the use of specific devices or therapeutic techniques to help address the underlying mechanical problems that have resulted in injury.
4. Every good corrective exercise program will involve development and coordination of the core muscles during this program. Without a strong core for a solid foundation, other corrective exercises may not be effective in the end. (More on this in an upcoming blog)
5. Be cognizant of your limitations while recovering from the injury, adjust your workouts accordingly until the problem is resolved, then develop a progressive return to specific activity plan taking advantage of your new mechanical corrections. (alternative methods to maintaining your conditioning while injured was the topic of two previous blog posts).
6. Don't be closed minded to the fact that some of your workout choices, athletic gear (shoes, bike, racquet, etc), and workout conditions may be contributing to your problem. Be prepared to make changes in areas within your comfort zone. Athletes who find the right sports medicine professional and trust and adhere to their recommendations typically respond the best.
As promised in the last blog, we will focus on providing information to help guide you through all of the misinformation. The next five blogs will focus on information from the five tips above to arm you with information to win the overuse injury battle and avoid the chronic injury asylum.
Until then, train hard, train safe, and train smart!
Monday, April 29, 2013
"Squeezing" the Most Out of Your Recovery
Recently, compression technology has gained popularity as means of enhancing recovery. There are several methods of compression available to athletes and all work to assist the body in minimizing the effects of heavy training. Common methods available to athletes are compressive garments and mechanical compressive devices. Both have their benefits. Picking the appropriate method hinges on many factors.
Compression Recovery Theories
The theory behind compression technology is often misunderstood. Without being overly scientific, to be effective, compression must surround the body part at a high enough level to affect fluid movement between tissues and blood vessels, ultimately ending with fluids being moved through tissues and into the lymphatic system for removal. With most compression devices, compression is graded with the distal portion of the device (furthest away from the heart) applying more pressure than the proximal portion of the device (closest to the heart). The lymph system runs in this same direction, and the graded pressure promotes movement of fluids in the appropriate direction.
Clinically, the use of compressive devices has been associated with creating pressures correlated to diastolic blood pressure (approximately 80 mmHg in a normal person). However, arterial capillary pressures are approximately 30mmHg, and any pressures that exceed this theoretically should promote fluid re-absorption and movement of the lymph. Squeezing of the lymph channels and increasing the hydrostatic pressure of the tissues can be accomplished with as little as 40-50 mmHg and will force fluids and edema through blood vessels promoting removal as well. The importance of active movement of the body part, muscular contractions, and elimination of the effects of gravity in conjunction with compression enhances the fluid removal effects even greater (and are explained in a previous blog). Understanding these pressure numbers is important when choosing your method of compression.
Mechanical Compression Devices.
 |
| Normatec MVP Sequential Compression |
Compression Garments
Another popular trend has been the application of compression garments before, during, or after competition. Research on the application of these devices is sparse. Considering the pressure numbers needed to achieve the desired results, it is a "buyer beware" market. Before purchasing compression garments, it is wise to find out the pressure numbers provided by the garment. Reputable manufacturers will have these numbers available to the consumer. Make sure to purchase compression garments that will provide the minimum pressures needed to have a desired effect.
Don't Overlook the Obvious
Exercise and movement of body parts promotes fluid movement and exchange. Though compression garments might not provide enough pressure to cause a fluid shift independently, use of compression garments in conjunction with light exercise during recovery may have a positive effect. Certainly, the use of compression garments in conjunction with elevation will provide good results. Elevating the limbs is the most overlooked, yet likely one of the most effective tools available in recovery. So, after your next strenuous workout, don't be afraid to cool down, stretch, shower, and then spend some quality time relaxing and recovering with your feet elevated. Adding one of the devices above will simply enhance what mother nature wants us to do to recover.
Future blogs will report on other methods used to improve chances of training healthy and enhancing recovery.
Until next time, train safe and train smart!
Friday, April 26, 2013
Don't Want to Lose Conditioning While You Heal Up? -- " Go Off the Deep End!"
The biggest fear most athletes face when they get injured is the loss of hard earned conditioning levels. The biggest reason that most "Type A" athletes don't appropriately recover from overuse injuries is inappropriate rest for recovery due to these overwhelming fears. There are as many recommendations for conditioning while injured as there are experts in the field. Particularly if an athlete is heading into their competitive season, the methods of conditioning used while rehabilitating injury should have three major considerations (1) picking an activity that will not exacerbate the injury (2) find an activity that utilizes the same major muscle groups used that mimics the athlete's sport activity and (3) provides cardiovascular fitness levels equal to that experienced during the athletes land based sport activity.
In the previous blog, I covered necessary means and guidelines for using aquatic therapy to adjust varying amounts of stress on the body while healing from injury. One of the great aspects of using water during rehabilitation is the ability to perform functional activities that mimic the activities performed on land. Obviously, running in the water will mimic the muscles used on land, only in a reduced weight bearing environment (see the previous blog). Additionally, adding multidirectional movements in the water can help strengthen key areas of the athletes body including the "core". Jumping activities, strength activities, and other resistance activities can be performed in the water under the direction of an appropriate licensed athletic health care professional to enhance athletic performance even while recovering from injury.
Maintaining appropriate conditioning levels in the water, however, requires special considerations to maintain high cardiovascular performance. It is readily recognized in scientific sports medicine journals that maintaining maximal oxygen capacity is achievable at levels in water equal to land based training as long as the intensity of the cardiovascular exercise in the water is at a level that matches that land based training. What most athletes don't realize is heart rate on land does not equal heart weight when submerged in water. Due to the pressure of the water on the submerged body, there is an approximate 35% increase in heart mean stroke volume, a decrease in blood pressure, and an increase in cardiac output that provides more oxygenated blood to the working muscles (another reason to use water to help the healing process). Due to these effects, target heart rates in water should be 17-20 beats per minute lower than on land to produce equivalent cardiovascular effects. Athletes not aware of this nugget of information end up trying to exercise at heart rate values equal to land and become frustrated with water conditioning, finding they cannot get their heart rate up to land based levels in water without going anaerobic and fatigue out much too quickly. Likwise, an athlete conditioning in water that does not monitor their heart rate values will fall into a "comfort zone" in the water at levels not sufficient enough to stimulate the desired cardiovascular effects and aerobic conditioning will suffer.
As an example of appropriate conditioning in the water, an athlete wanting to perform a long run at 155 beats per minute should run at an intensity level in water that is135-138 beats per minute for the same amount of time they would run on land and will have the same cardiovascular effect without traumatizing their injury. Scientific studies have shown athletes can maintain their V02max values through water running as long as appropriate levels are achieved. The literature is full of examples of athletes that have rehabilitated common overuse injuries of the lower extremities, conditioning only in deep water running for up to eight weeks without running on land and returned to championship levels of performance within days of being released to run on land. It seems almost too easy to be true, but armed with the right information, training, and rehabilitation plan, it is more than possible.
As always, if you are going to train hard, you might as well train smart! If not, injuries will occur or goals will never be achieved. This is never more true than trying to train while injured.
In the previous blog, I covered necessary means and guidelines for using aquatic therapy to adjust varying amounts of stress on the body while healing from injury. One of the great aspects of using water during rehabilitation is the ability to perform functional activities that mimic the activities performed on land. Obviously, running in the water will mimic the muscles used on land, only in a reduced weight bearing environment (see the previous blog). Additionally, adding multidirectional movements in the water can help strengthen key areas of the athletes body including the "core". Jumping activities, strength activities, and other resistance activities can be performed in the water under the direction of an appropriate licensed athletic health care professional to enhance athletic performance even while recovering from injury.
Maintaining appropriate conditioning levels in the water, however, requires special considerations to maintain high cardiovascular performance. It is readily recognized in scientific sports medicine journals that maintaining maximal oxygen capacity is achievable at levels in water equal to land based training as long as the intensity of the cardiovascular exercise in the water is at a level that matches that land based training. What most athletes don't realize is heart rate on land does not equal heart weight when submerged in water. Due to the pressure of the water on the submerged body, there is an approximate 35% increase in heart mean stroke volume, a decrease in blood pressure, and an increase in cardiac output that provides more oxygenated blood to the working muscles (another reason to use water to help the healing process). Due to these effects, target heart rates in water should be 17-20 beats per minute lower than on land to produce equivalent cardiovascular effects. Athletes not aware of this nugget of information end up trying to exercise at heart rate values equal to land and become frustrated with water conditioning, finding they cannot get their heart rate up to land based levels in water without going anaerobic and fatigue out much too quickly. Likwise, an athlete conditioning in water that does not monitor their heart rate values will fall into a "comfort zone" in the water at levels not sufficient enough to stimulate the desired cardiovascular effects and aerobic conditioning will suffer.
As an example of appropriate conditioning in the water, an athlete wanting to perform a long run at 155 beats per minute should run at an intensity level in water that is135-138 beats per minute for the same amount of time they would run on land and will have the same cardiovascular effect without traumatizing their injury. Scientific studies have shown athletes can maintain their V02max values through water running as long as appropriate levels are achieved. The literature is full of examples of athletes that have rehabilitated common overuse injuries of the lower extremities, conditioning only in deep water running for up to eight weeks without running on land and returned to championship levels of performance within days of being released to run on land. It seems almost too easy to be true, but armed with the right information, training, and rehabilitation plan, it is more than possible.
As always, if you are going to train hard, you might as well train smart! If not, injuries will occur or goals will never be achieved. This is never more true than trying to train while injured.
Saturday, April 20, 2013
Using Effective Aquatic Therapy Techniques Can "Take A Load Off"
Repetitive pounding from weight bearing activities is a mechanism of injury for many sport related maladies. Lower extremity overuse injuries plague the athletics world and occur from many factors (stay tuned for a later blog on this, it is quite interesting). Tibial stress fractures, femoral stress fractures, metatarsal stress fractures, achilles tendonitis, chondromalacia, and patellar tendonitis are all common injuries that are impacted by repetitive loading of the lower extremity.
Typically, patients with chronic stress related injuries will be instructed to remain active (but reduce or eliminate weight bearing activities), receive appropriate therapy on the injury, strengthen the affected area, and once healed, "gradually" move back into activity. Most Type A personality athletes take this as "get back to training as soon as I start to get a little relief from rest and therapy". This is a natural response for competitive people but certainly not the best course of action to return from a significant stress related injury...........re-injury inevitably occurs. Elite athletes with stress related injuries try to avoid this mistake by incorporating specific methods of training during their recovery and rehabilitation. By utilizing aquatic therapy as part of the rehabilitation program, top athletic health care professionals are able to manage injury restrictions, yet maintain or improve conditioning, strengthen the injured area, and formulate a measurable graduated return to full weight bearing to avoid re-injury after the athlete returns to competition.
Gradual Return to Full Weight Bearing
For many stress related lower extremity injuries, reduction of weight bearing is necessary for the injury to heal, but total non-weight bearing is rarely prescribed. Partial or restricted weight bearing is often chosen because the body needs this stimulation to propagate the healing process. The effects of buoyancy in water allows performance of sport related activities in various levels of "measurable" weight bearing. To estimate the percentage of weight bearing while in the water, there is a simple rule of thumb:
0% Weight Bearing = Submerged but unable to touch the floor of the pool
10% Weight Bearing = Submerged in water up to the sternoclavicular joint (base of the neck)
25% Weight Bearing = Submerged in water up to the xiphoid process (just below the chest)
50% Weight Bearing = Submerged in water up to the ASIS (bones on the front of the hips)
(These are guidelines, exact weight bearing numbers depend on sex, body type, and body composition)
If needed, non-weight bearing activities can be performed in water deep enough the bottom of the pool can't be contacted. The use of flotation devices on the torso allows the athlete to perform physical activities in the water in a non-weight bearing capacity. Commonly used flotation devices by top professionals are the AquaJogger, the Zero G Flotation Suits, and the WetVest. Whatever device is chosen should provide enough buoyancy to allow the athlete to float neck deep in the water but maintain an upright running position. All are effective and can be purchased online and are a great investment for the athlete relegated to water workouts for any extended period of time.
For those that don't have the luxury of elite athletes' access to a custom pool, there is no need to worry. Utilization of various depths of water in any pool can be performed to achieve these gradual increases in weight bearing. Once cleared by an athletic health care professional to resume gradual weight bearing, start at the appropriately prescribed level in the pool and perform running activities at that depth. As exercises are tolerated without exacerbation of symptoms, gradual movements into more shallow areas of the pool can occur to add more weight bearing. As the level of weight bearing increases, steps must be taken to monitor for the return of any symptoms. Return of symptoms may indicate that progression has occurred too quickly, and a return to previously used deeper depths until the body has time to respond and adapt may be warranted. Once running is performed at 50% weight bearing with no increase in symptoms, the athlete is normally ready to resume land based training (again increasing the workouts in a logical graded fashion over time).
Keeping the Pressure on the Injury
Hydrostatic pressure is the amount of pressure applied to the body while submerged in water. The deeper the body, the more pressure is exerted. (This is the cause of the sensation of the ears needing to "pop" when diving in deep water and the cause of some dangerous conditions in individuals who deep sea dive.) What does this have to do with treating injuries? Hydrostatic pressure can be utilized to control and reduce swelling at appropriate depths. For every foot of depth in the water, 22.4 mmHg is equally exerted around the body part (remember mmHg are the units of pressure used in determining blood pressure). For the normal athlete standing in 5 feet of water, there will be 112 mmHg pressure exerted on the feet with gradually less pressure exerted on the legs as you approach the surface of the water. The average person's diastolic blood pressure is 80mmHg, so even if the water is warm at that depth, swelling will not occur. In fact, hydrostatic pressure is significant enough that swelling will reduce due to the pressure and move upward into the body and removed through the lymph system. This effect can be further enhanced with movement in the water since muscular contractions also assist in the movement of swelling. Taking advantage of hydrostatic pressure is one of the "secrets" used to manage injuries of the foot, ankle, and knee by top level athletic health care professionals.
Something to Consider
Hydrostatic pressure at 5 feet of depth exceeds the pressure exerted by many popular compression and recovery devices, leading to the conclusion that walking in deep water may be a means to promote recovery after hard workouts (especially if the water is cool). Try it some time. If you think it doesn't work consider this: have you ever noticed that after a long swim workout your clothes fit a little looser initially? Fluid shifts cause minor changes in limb girth until gravity reverses its effects. So the consumer tip for the day is -- don't go shopping for pants immediately after swimming or you might be likely to go home a few days later to find they don't fit quite like they did in the store!
Are There Contraindications To Using Aquatic Therapy?
Aquatic therapy is not recommended in some instances including but not limited to:
1. Untreated infectious disease (the patient has a temperature/fever)
2. Open wounds or unhealed surgical incisions
3. Contagious skin diseases
4. Serious cardiac conditions (due to the centralization of blood flow caused by hydrostatic pressure)
Athletes with pulmonary conditions should not be submersed more than 85% due to the resistance of chest wall expansion by the water creating subsequent complications. It is always wise to check with an athletic health care professional before commencing a program including aquatic therapy.
Helpful Hints and Tips to Make Aquatic Therapy Effective
1. For individuals who are going to be performing partial weight bearing water running activities in the pool for extended periods of time, footwear should be worn in the water. Without footwear, blisters on the bottom of the feet will likely occur as the skin weakens and slippage on the bottom of the pool occurs. An older pair of running shoes will suffice (make sure they are cleaned and free of dirt, etc). Specialized water running shoes (AQx shoes) are available are very effective in protective the feet during water running.
2. Weight bearing estimations assume a normal body position with the hands in the water at depths above the waist. Moving the arms out of the water will increase weight bearing (many people will do this to move faster in the water due to better traction on the bottom of the pool from the increase in weight bearing) and will affect the amount of impact experienced during activity.
3. Exercise must be performed at an appropriate intensity to elicit the desired conditioning effect. Specific guidelines for how to maintain conditioning levels, isolated injury strengthening, increasing core strength, and other hidden gems of aquatic therapy is the topic for the next blog!
Be well. Be informed. Be Active!
Typically, patients with chronic stress related injuries will be instructed to remain active (but reduce or eliminate weight bearing activities), receive appropriate therapy on the injury, strengthen the affected area, and once healed, "gradually" move back into activity. Most Type A personality athletes take this as "get back to training as soon as I start to get a little relief from rest and therapy". This is a natural response for competitive people but certainly not the best course of action to return from a significant stress related injury...........re-injury inevitably occurs. Elite athletes with stress related injuries try to avoid this mistake by incorporating specific methods of training during their recovery and rehabilitation. By utilizing aquatic therapy as part of the rehabilitation program, top athletic health care professionals are able to manage injury restrictions, yet maintain or improve conditioning, strengthen the injured area, and formulate a measurable graduated return to full weight bearing to avoid re-injury after the athlete returns to competition.
Gradual Return to Full Weight Bearing
For many stress related lower extremity injuries, reduction of weight bearing is necessary for the injury to heal, but total non-weight bearing is rarely prescribed. Partial or restricted weight bearing is often chosen because the body needs this stimulation to propagate the healing process. The effects of buoyancy in water allows performance of sport related activities in various levels of "measurable" weight bearing. To estimate the percentage of weight bearing while in the water, there is a simple rule of thumb:
0% Weight Bearing = Submerged but unable to touch the floor of the pool
10% Weight Bearing = Submerged in water up to the sternoclavicular joint (base of the neck)
25% Weight Bearing = Submerged in water up to the xiphoid process (just below the chest)
50% Weight Bearing = Submerged in water up to the ASIS (bones on the front of the hips)
(These are guidelines, exact weight bearing numbers depend on sex, body type, and body composition)
If needed, non-weight bearing activities can be performed in water deep enough the bottom of the pool can't be contacted. The use of flotation devices on the torso allows the athlete to perform physical activities in the water in a non-weight bearing capacity. Commonly used flotation devices by top professionals are the AquaJogger, the Zero G Flotation Suits, and the WetVest. Whatever device is chosen should provide enough buoyancy to allow the athlete to float neck deep in the water but maintain an upright running position. All are effective and can be purchased online and are a great investment for the athlete relegated to water workouts for any extended period of time.
For those that don't have the luxury of elite athletes' access to a custom pool, there is no need to worry. Utilization of various depths of water in any pool can be performed to achieve these gradual increases in weight bearing. Once cleared by an athletic health care professional to resume gradual weight bearing, start at the appropriately prescribed level in the pool and perform running activities at that depth. As exercises are tolerated without exacerbation of symptoms, gradual movements into more shallow areas of the pool can occur to add more weight bearing. As the level of weight bearing increases, steps must be taken to monitor for the return of any symptoms. Return of symptoms may indicate that progression has occurred too quickly, and a return to previously used deeper depths until the body has time to respond and adapt may be warranted. Once running is performed at 50% weight bearing with no increase in symptoms, the athlete is normally ready to resume land based training (again increasing the workouts in a logical graded fashion over time).
Keeping the Pressure on the Injury
Hydrostatic pressure is the amount of pressure applied to the body while submerged in water. The deeper the body, the more pressure is exerted. (This is the cause of the sensation of the ears needing to "pop" when diving in deep water and the cause of some dangerous conditions in individuals who deep sea dive.) What does this have to do with treating injuries? Hydrostatic pressure can be utilized to control and reduce swelling at appropriate depths. For every foot of depth in the water, 22.4 mmHg is equally exerted around the body part (remember mmHg are the units of pressure used in determining blood pressure). For the normal athlete standing in 5 feet of water, there will be 112 mmHg pressure exerted on the feet with gradually less pressure exerted on the legs as you approach the surface of the water. The average person's diastolic blood pressure is 80mmHg, so even if the water is warm at that depth, swelling will not occur. In fact, hydrostatic pressure is significant enough that swelling will reduce due to the pressure and move upward into the body and removed through the lymph system. This effect can be further enhanced with movement in the water since muscular contractions also assist in the movement of swelling. Taking advantage of hydrostatic pressure is one of the "secrets" used to manage injuries of the foot, ankle, and knee by top level athletic health care professionals.
Something to Consider
Hydrostatic pressure at 5 feet of depth exceeds the pressure exerted by many popular compression and recovery devices, leading to the conclusion that walking in deep water may be a means to promote recovery after hard workouts (especially if the water is cool). Try it some time. If you think it doesn't work consider this: have you ever noticed that after a long swim workout your clothes fit a little looser initially? Fluid shifts cause minor changes in limb girth until gravity reverses its effects. So the consumer tip for the day is -- don't go shopping for pants immediately after swimming or you might be likely to go home a few days later to find they don't fit quite like they did in the store!
Are There Contraindications To Using Aquatic Therapy?
Aquatic therapy is not recommended in some instances including but not limited to:
1. Untreated infectious disease (the patient has a temperature/fever)
2. Open wounds or unhealed surgical incisions
3. Contagious skin diseases
4. Serious cardiac conditions (due to the centralization of blood flow caused by hydrostatic pressure)
Athletes with pulmonary conditions should not be submersed more than 85% due to the resistance of chest wall expansion by the water creating subsequent complications. It is always wise to check with an athletic health care professional before commencing a program including aquatic therapy.
Helpful Hints and Tips to Make Aquatic Therapy Effective
1. For individuals who are going to be performing partial weight bearing water running activities in the pool for extended periods of time, footwear should be worn in the water. Without footwear, blisters on the bottom of the feet will likely occur as the skin weakens and slippage on the bottom of the pool occurs. An older pair of running shoes will suffice (make sure they are cleaned and free of dirt, etc). Specialized water running shoes (AQx shoes) are available are very effective in protective the feet during water running.
2. Weight bearing estimations assume a normal body position with the hands in the water at depths above the waist. Moving the arms out of the water will increase weight bearing (many people will do this to move faster in the water due to better traction on the bottom of the pool from the increase in weight bearing) and will affect the amount of impact experienced during activity.
3. Exercise must be performed at an appropriate intensity to elicit the desired conditioning effect. Specific guidelines for how to maintain conditioning levels, isolated injury strengthening, increasing core strength, and other hidden gems of aquatic therapy is the topic for the next blog!
Be well. Be informed. Be Active!
Friday, April 19, 2013
Just Because You Are Injured Doesn't Mean Your Season Is All Washed Up - Use Aquatic Therapy Correctly To Enhance Your Injury Recovery and Continue Toward A Maximal Performance
Each time I go to the local pool for a swim session, I see individuals in the deep water performing various activities to "get a workout while they are injured". Many have taken to the water on the advice of a health care professional to participate in a subsititue activity to maintain conditioning while minimizing injury stress as they wait out the necessary healing process. Unfortunately, in my conversations with some of these people, I learned that many leave the water with a healed injury only to find they have lost their previously hard-earned conditioning levels and regressed on their training plans due to a lack of understanding on how to take advantage of the water.
Utilizing water for therapy has been described in literature for over 2,000 years. Since Archimedes took his bath, medical professionals have progressed the understanding of how to effectively use water in injury management. Many top athletic health care professionals have rediscovered the benefits of aquatic therapy in the past decade. Medical journals have documented that training in an aquatic enviroment has beneficial effects for the injured athlete. Aquatic therapy workouts provide an environment of reduced weight bearing, increased resistance to movement, circumferential progressive compression of submerged body parts, and the ability to exercise at levels to not only maintain, but improve cardiovascular conditioning. The literature is scattered with case studies of athletes who have exercised in water during injury rehabilitation and have returned to land based activities with no drop in aerobic conditioning. Why is it, then, that the average injured age-grouper athlete doesn't realize the same results with substitute water workouts as do elite level athletes? The secret lies in a few of the particular physical properties of water and attention to specific execution of activities being performed to take advantage of those properties. Armed with this information, the average injured age-grouper can utilize their local pool to get the same results as elite level athletes.
The rediscovery of the advantages of aquatic therapy has led many professional sports teams and universities to install specialized therapy pools with submerged treadmills, moving walls of water, and floors that change depth to take advantage of this great tool. Athletic health care professionals are utilizing these pools for a variety of purposes:
(1) To reduce or eliminate the effects of gravity while performing an activity to mimic a land based activity (i.e. running).
(2) To perform activities at appropriate cardiovascular levels to achieve similar goals of land based workouts.
(3) To utilize the pressure of water to reduce inflammation and edema in the lower extremities.
(4) To increase strength and mobility in specific areas and reduce the likelihood of reinjury once healed.
Fortunately, a specialized pool is not needed to perform an overwhelming majority of exercises used to achieve these goals. The next few blogs will be dedicated to revealing secrets and introducing aquatic therapy activities and tips used by top athletic health care professionals to achieve optimal injury management and conditioning while injured.
Utilizing water for therapy has been described in literature for over 2,000 years. Since Archimedes took his bath, medical professionals have progressed the understanding of how to effectively use water in injury management. Many top athletic health care professionals have rediscovered the benefits of aquatic therapy in the past decade. Medical journals have documented that training in an aquatic enviroment has beneficial effects for the injured athlete. Aquatic therapy workouts provide an environment of reduced weight bearing, increased resistance to movement, circumferential progressive compression of submerged body parts, and the ability to exercise at levels to not only maintain, but improve cardiovascular conditioning. The literature is scattered with case studies of athletes who have exercised in water during injury rehabilitation and have returned to land based activities with no drop in aerobic conditioning. Why is it, then, that the average injured age-grouper athlete doesn't realize the same results with substitute water workouts as do elite level athletes? The secret lies in a few of the particular physical properties of water and attention to specific execution of activities being performed to take advantage of those properties. Armed with this information, the average injured age-grouper can utilize their local pool to get the same results as elite level athletes.
The rediscovery of the advantages of aquatic therapy has led many professional sports teams and universities to install specialized therapy pools with submerged treadmills, moving walls of water, and floors that change depth to take advantage of this great tool. Athletic health care professionals are utilizing these pools for a variety of purposes:
(1) To reduce or eliminate the effects of gravity while performing an activity to mimic a land based activity (i.e. running).
(2) To perform activities at appropriate cardiovascular levels to achieve similar goals of land based workouts.
(3) To utilize the pressure of water to reduce inflammation and edema in the lower extremities.
(4) To increase strength and mobility in specific areas and reduce the likelihood of reinjury once healed.
Fortunately, a specialized pool is not needed to perform an overwhelming majority of exercises used to achieve these goals. The next few blogs will be dedicated to revealing secrets and introducing aquatic therapy activities and tips used by top athletic health care professionals to achieve optimal injury management and conditioning while injured.
Tuesday, August 7, 2012
Even the Best Laid Plans...............
It has been a long while since I last blogged about sports health issues. I have spent the last several months performing my own "lab" experiment in training, preparing for, and competing in an Ironman Triathlon. So, I am blogging this post-Ironman Texas race report and infusing my usual (and hopefully helpful) information of what I learned along the way.
Why Do It?
This is the question that is asked by all who don't. Any one of the three events of an Ironman is a daunting task. Many people would relish in specifically training for and completing a century bike ride or complete a marathon. Who in their right mind would want to do both in the same day and throw in a 2.4 mile open water swim to start for good measure, being allowed a maximum of 17 hours to complete the event? Surprisingly, more than you think. There are 30+ WTC sanctioned Ironman races per year worldwide. With an average of 2,000 people per race, there are nearly 60,000 people who attempt this feat yearly. Elite level (genetically freakish) professional triathletes complete the race in around 8 hours, but the heart and soul of the sport is the average age-grouper who holds a full-time job and has a family that completes this that fascinated me. I would watch it every year on TV and see video clips of the ends of these races and see these "average Joe's" accomplish this and say to myself "how is this possible?" Admittedly, athletically, I am not an endurance athlete by nature. I have always participated in events that were more anearobic in nature and excel in events that are more high intensity interval based in general (more later on how that affects your training). However, having enjoyed improved health and fitness by participating in shorter and mid-distance triathlons over the past few years, I decided to embark on a journey of trying to discover exactly how it is possible that this ultra-endurance event was being completed by people like myself. In essence, I decided to perform my own self-experiment in human exercise physiology, and approached the preparation for the event in this way.
Data, Data, and more Data
I am somewhat of a data geek on tracking issues involving sports health and performance, so I entered this project armed with a heart rate monitor/GPS device (tracking heart rate, pace, etc) for my running and a HR monitor coupled with a power meter on my bike for my training rides. I downloaded all information into TrainingPeaks.com and was utilizing their performance tracking software. I used this information only to track my progress and gauge the intensity and of the workouts. Training for endurance events is more about pacing and maintaining manageable levels of intensity (unless you are one of the aforementioned genetically freakish individuals that can race at a high intensity for 8+ hours). I thought is was particularly important to monitor my progress of fitness and body response to training to understand what levels of intensity I could work out at and keep my heart rate in a zone that would allow me to perform continuous exercise for 13+ hours. The data helped me to objectively track progress, but I avoided the dreaded "paralysis by analysis" of over-analyzing unnecessary information.
Obstacles Even Before Starting
What made this even more intriguing for me was to have several obstacles to try to overcome in preparation for this event.
1. A job that requires steady 60-80 hour work weeks. Time management was going to be important.
2. Bone-on-bone arthritis/condition of the knee. Two previous meniscus surgeries in one knee have left me with no cartilage on the medial side of the knee. This was also going to be an experiment on utilizing many of the medical therapies that I use on our athletes to see how manageable this was going to be. My orthopedic surgeon friends shook their heads when I told them what I was going to attempt.
3. Lack of heat acclimitization and opportunities to race. Winters in Iowa relegate most people to cycling on an indoor trainer and running indoors for the winter months. Spring weather is unpredictable and very windy in central Iowa. This was honestly my biggest known obstacle. I am a very heavy sweater even in mild conditions and have had issues with electrolyte imbalances and maintaining proper hydration levels as I have gotten older. My body has not typically responded well to sudden climate changes and exercise conditions. This was going to be a total crapshoot being that most of the training would be in Iowa and racing in Houston in mid-May could be pretty warm.
4. Never experienced exercising for an ultra-endurance event. I had no gauge as to how my body was going to respond not only to the environment, but to being exposed to exercise for that long of a time frame.
Most people say that the toughest part of the Ironman is getting to the starting line and surviving all of the training. I was armed with what I considered an above normal understanding of the above limitations and resources to monitor my progress, and I was convinced that I could come up with a plan to not only survive, but finish my first attempt at an Ironman.
The Preparation
The fall months were spent maintaining fitness in all three disciplines around a hectic college football schedule, but all-in-all, training went relatively well ranging from 7-10 hours per week of training. Full-on Ironman training started in the end of December (while we were at the Pinstripe Bowl) and I utilized a combination of training programs from various "experts" who are highly published. I constructed the program to meet and challenge my strengths, build my weaknesses, and timed to avoid injury problems (particularly controlling the amount of damage occuring to my arthritic left knee). In the end, over 24 weeks of training, I completed 97% of my scheduled workouts and distances. My swimming was the better than at any point in my nearly 4 years of triathlon. Biking was certainly different, concentrating on longer rides with less intensity (more on that later), and running was manageable. I had decided early on that for any runs that were going to be longer than 60 minutes, I was going to train with a popular method of running three minutes and walking 1 minute and did all endurance runs using that method. I planned on using that method for the entire run of the marathon for as long as I could hold out. I should mention that my longest competition run ever was 13.1 miles (done in a half-ironman in Kansas two years ago). It's funny that most people who know me from high school and college would remember my accomplishments as a runner on the track, but running has become my nemesis as I have gotten older. I admire people who run marathons, but you will never catch me signing up for one unless it is at the end of an Ironman. Typical training weeks were 8-14 hours with most of the endurance training being done on the weekends (too many 4+hour rides on the indoor trainer watching movies for my liking). In the end, I had dialed in what power levels I could hold on the bike for 6+hour of riding, was comfortable with the pace I could hold on the run for 2 1/2 hours, and was very confident in my swim. I had carefully monitored what my approximate fluid intake would need to be (measured how much fluids I was losing factoring in fluid intake on all long rides) along with nutritional needs to get to the marathon without "bonking". The only knowledge I had of the race course was a podcast I listened to by the people from Endurance Nation who had ridden the course and described (in very accurate detail) where the specific challenges of the bike course loomed. I had no "goal time" for this race. My one and only goal was to finish, but based on training times, I had a realistic shot at anywhere from 12 1/2 - 13 1/2 hours to complete the event.
The Pre-Race
I drove to Houston from Ames four days prior to the event (thanks to my father for riding along), checked in two days ahead of time at the mandatory check in (highly organized and very friendly people), and attended the athletes banquet. They say every person in an Ironman has a story, and this was an inspiring evening of speakers and Mike Reilly the voice of Ironman hosting. The day prior to the race involved checking in the bike and transition bags. I was able to meet current women's Ironman World Champion Chrissie Wellington (for a 2nd time) and listened to her speak about her new book "Life Without Limits" and had her sign a copy (I highly recommend this to athletes of both genders). It was the second time for me meeting her, and I will say that professional athletes from all sports could learn something from her. She is genuinely one of the most endearing people in sport.
Having stayed at my sister's house about 30 minutes from the starting line, we headed out early (4:30am) checked into transition, put last minute items into the special needs bag, and headed out for the .8 mile hike to the start of the swim. Temperatures were about 75 degrees, and the water was warm enough that it was not wet-suit legal for participating for awards. I obviously wasn't going to be in the running for any awards, but chose to participate without a wetsuit to attempt to stay cooler in the water (you get hotter than you think). I didn't want to risk any more possibilities of dehydration than I needed to.
I typically get a little nervous before most of my events, but I was strangely calm before the start of this one. It was unbelievably inspiring to be out there with nearly 2,600 people. I was anxious to get the day started to see what was going to happen.
The Swim
If you have never seen the start of an Ironman race, it is one of the coolest spectacles in sport. Being in the mix, however, is even more of a spectacle. Starting a race in the water with 2,600 people at once is a little like trying to get out of a crowded pool if there was a shark attack.....it is chaos......and man, is it fun! This was taken from the bridge seconds after the start of the swim at the race. The huge group out in the water are those swimming without wetsuits, those using wetsuits started 10 minutes later. The IM Texas swim is kind of strange with an approximate .8 mile swim out into the lake, .8 mile swim returning to near the start, then a .8 mile swim up a canal on the left side of the picture to get to the bike transition area. The water was warm. Knowing that I have had trouble with overheating in warm water races in the past two years, I opted to not wear a wetsuit, but did wear a recently purchase Blue Seventy speed suit that was AWESOME! I started near the back of the pack giving myself a little room and trying to avoid congestion (I hate people swimming up on my legs). Within the first 800 meters, I had worked my way up to the pack and at the turn to come back felt pretty good. I was maintaining what I thought was a reasonable pace. I did have a moment of panic when I looked at my watch at the turnaround and misread the time (I thought I was on pace to finish 30 minute slower that what I anticipated at that point in the race, but didn't panic and just moved on). At the 1.6 mile mark, we hit the turn to swim up the canal, and by that point in the race, you are typically swimming with people your own speed, but I seemed to be passing quite a few people. The canal is approximately 20 yards wide, so it was destined to be congested with swimmers, and I tried to swim up the canal (which had several small "s" type curves in it) on the left hand side taking what appeared to be the shortest route. My hand started striking something that I assumed was another swimmer, but when I slowed up, found that I was actually hitting the bottom of the canal with my hand. I stood up and was only waist deep in the water and could see other swimmers on the right making good progress. I learned quickly to make any time in the water I needed to be in an area of the canal that had been dug out for tourist boats and moved over into a traffic line with other swimmers. The canal swim was very strange. Because of the huge number of swimmers making waves at once, the turbulence of the water was tremendous. There were so many side-to-side waves in the canal, it seemed as if we were swimming upstream (which was virtually possible, since there was no current in the canal). Regardless, I pulled in at the end of the swim only to be very surprised that I had misread my watch earlier, and had actually bettered what I thought would be a reasonable swim time for my first Ironman and got out of the water in a little over 1 hour and 10 minutes. I was not overly tired, and was thrilled with the start of my day. I decided I didn't need to be in any great hurry to get through transition (I wasn't really competing for a Kona spot) and decided to walk to pick up my transition bag and insure that my heart rate was in a very manageable spot. As I walked into the transition area, I noted that not many transition bags had been picked up in my age group and was thrilled to find out that I had finished in the top 20% of all swimmers and done very well in my age group. I picked up my transition bag, put on my cycling shoes, socks, and jersey (opting for a light weight cycling jersey over my traditional tri-racing top to battle effects from long exposure to the sun and remain cooler), grabbed my nutrition, took in a healthy amount of sports drink, and picked up the bike.........time to get my ride on!
The Bike
I was forewarned on a podcast regarding the race that the bike, though it appeared fairly flat, would be challenging due to the last 56 miles of the course likely being into a headwind and a portion of it on chip-seal roads. Over the course of the winter, I had paid particular attention on my longer rides to my fluid loss rate and the average power I was able to maintain during all 4+ hour rides. My plan was to stay within those limits for the entire ride regardless of the speed of other competitors. I settled into a comfortable pace early within my limits and averaged over 20mph during the first 40 miles of the race. Roads were great, and it was apparent that we were being pushed by a slight headwind. Despite my better than expected speed, I was being passed by a lot of competitors, but I was determined to stay in a range of power that I knew I could handle. At around 40 miles, we entered the Sam Houston State Forest. The ride was beautiful, but the roads (or dare I say single car asphalt trails) were not. The temperatures were starting to rise, and there was no wind in the forest and the hills became challenging a few times. As we exited the forest at around mile 52, we turned back into a now heavier headwind and entered about a 20+ mile stretch of the course where the roads were chip-seal asphalt. I new the temperatures were starting to get up there, and should have known there were going to be problems when I saw the larger-than-expected number of competitors in the medical tent somewhere between mile 60-70. I witnessed more than one person veer off the road and crash due to disorientation from dehydration. I believed I had a solid nutrition plan being very concerned with my natural loss of large amounts of sodium when I exercise, and drank a minimum of 24 oz of either water or sports drink every half-hour along with energy chews and about 500mg of sodium per hour. By my best calculations while on the bike I drank roughly 240 oz of fluids and took in about 1600 calories and over 4000mg of sodium over the course of the ride. At about mile 90, I saw my awesome wife who drove out of town to catch up with me. It was terrific to see her out there, and just the push I needed after riding into the wind for so long. At that point, I was hot and legs were getting fatigued, but still felt like I had controlled my effort pretty well. That would all change 5 miles later. With roughly 17 miles to go in the bike, I started to catch some minor cramps in my hamstrings which I was a little concerned with, but also figured was expected since we had ridden basically 50 miles into a headwind. True to the podcast's predictions, the chip-seal roads had taken a toll on my legs and I finished the last 15 miles of the bike more fatigued than I would have liked. Only after returning to Iowa and plugging my bike computer in and downloading data did I discover that the last three hours of the bike, we were riding into a wind with temperatures ranging from 100-104F. No wonder I was tired?! Additionally, the computer told me I had hit it exactly on the mark for what heart rate and power I could maintain for 112 miles of biking. The last 10 miles of the bike were more about me being sick of riding than of overriding fatigue, and I was glad to return back to transition to get off the bike. My sister, niece, nephew, and brother-in law were near the transition area. As I passed my bike off to head for the tent to get my running gear, my sister yelled "Are you OK?" Being tired from biking and hot, I felt pretty good, but after running about 10 yards I was concerned why she was asking and I turned back to ask her why. She replied "because you don't look too good". I should have known then that it was going to be a challenging rest of the day.
The Transition
After talking to my sister briefly while I was moving through transition to get my running gear, I started to get pretty dizzy and didn't feel well. I had this happen on another occasion when I raced in temperatures over 100 degrees at the finish and ended up with an IV to recover. So, needless to say, I was concerned. Having not known exactly what the temperatures we were racing in, and considering I had tried to hydrate adequately throughout the bike, I was confused as to why I would be having these symptoms. At this point, I was only about 7 1/2 hours into the race and knew I had 9 1/2 hours to complete the marathon, so I decided to stay in transition until I started to feel better. I found a small area next to the changing tent in the shade, but was having a hard time cooling down and getting rid of my dizziness. There was virtually no breeze in the area and even in the shade I was having a hard time recovering. I normally am in transition about 3 minutes, but on this day, I camped out in there for about 45 minutes! After several bottles of water and cooling down, I started to feel better and headed out for the running course. Prior to leaving, I stopped by the medical tent and got a bottle of sports drink to try to replenish some calories and electrolytes, and was ready to take on the rest of what I knew would be a long run........
The Run
As I headed off on the run, I was planning on using my run 3 minutes, walk a minute strategy, but could only muster a 1 min run 1 min walk strategy due to some nagging cramping of the hamstrings. The IM Texas run course is an approximate 8 1/2 mile loop that is done three times. After walking/jogging (mostly walking) for the first 3-4 miles, I started to feel better and jogged until I started to have problems, then return to walking. This pattern continued for about the first 15 miles of the run. Since the loop ran through the woodlands canal area, I was able to see my wife and other relatives who were in the area on the run course several times. My wife had cut across the course and walked with me on a couple of occasions and she will never understand how important her support was at those points. I was very frustrated with my inability to sustain a run, but kept in mind the ultimate goal was the finish line. At about mile 15, I ran past a restaurant where another couple from Iowa who were there to do the race were (he had dropped out of the race due to heat earlier in the day) and I was encourage by them (they were both previous finishers and said I was looking great and only had one more lap to go). I really appreciated them at that point and moved on. At the end of the second loop I saw my wife and asked her to meet me at about mile 22 to do some walking. It was getting close to sundown and it was starting to finally cool off. I felt pretty good physically, but just felt exhausted and wanted to get through the last 8 miles. I still had about four hours to finish the race and felt it was well within my reach, I just needed to continue to be patient. The run course gets a little "curvy" when it heads out of the Woodlands, and with it now getting dark and with fewer competitors out there racing, I ended up getting a little confused and frustrated on the trails in the trees. At some point around mile 20, I decided I needed to take on more sports drink (I had only been drinking water and cola for the past 10 miles since my stomach was upset). As I entered the aid station, I asked a volunteer if I could take an entire bottle of sports drink to carry instead of a small cup that is normally used. The said "no problem" and I bent over the tub of ice where they were stored to get it. As I stood up, I knew I was in trouble. I became instantly dizzy and heart rate started to climb quickly (if you have ever stood up too quickly after lying down, think that x 10). I walked to the end of the aid station and felt it would be best to stop and sit for minute until things normalized. Unfortunately they didn't. In a strange set of circumstances in 90+ deg heat, I finally started to cool, but this time started cooling too much. What started as shivering advanced in to full fledge shaking which I couldn't control. Still having my senses, I was trying to determine if I was having a potassium problem or if I was suffering from further dehydration. I was prepared to deal with the dehydration, but was also growing concerned that a legitimate potassium problem was potentially dangerous. I still had over three hours to complete the last 6 miles and the medical personnel who had come by were leaving the decision of whether to continue to race up to me (they had learned what I do for a job and that made it pretty easy to communicate). After sitting there for roughly 20 minutes and symptoms worsening (rather than improving), I looked at my arm where I had written three key things for the race.....(1) only worry about things I could control, (2) be patient, it is a long day, and (3) family is my inspiration.
I promised my family that I wouldn't do anything stupid to try to complete this race (I have been known to be pretty stubborn when it comes to finishing physical activities) and as I sat there contemplating the cause of my significant inability to control my body temperature and the constant shaking that was occurring and worsening, I decided that I should withdraw from the race and truly live to race another day. It was painstakingly one of the most difficult and disappointing decisions I have ever had to make. I had signed up for this race, made a well-thought out program to complete this test and was planning on it being my only Ironman. The time sacrifices by both myself and my family over the course of the previous 10 months was pretty significant. However, without knowing the cause of my problems, I didn't think it was worth the risk to continue. Frustration and disappointment do not describe the moments following that decision. There I sat, 6 miles from the finish (only about 2 miles as the crow flies), able to hear Mike Reilly announcing the names of the finishers, and had to give in. I knew I was in need of medical attention. The outstanding medical personnel at the race attended to me right where I sat.One of the medical volunteers was a combat medic and inserted an IV into my arm right then and there.
Going to Medical
My biggest concern as I was being attended to was getting word to my wife and sister who would be waiting about two miles down the path for me to come through a final time. It was dark and I hate to worry her. She couldn't be reached on her cell phone (drained the battery doing race updates to all our friends and family), and I was worried that she would be worried. Regardless, they put me on a makeshift cot and onto a medical Gator and transported me to the medical tent. As I lay there crushed from disappointment I was simultaneously freezing from the open air wind in my sweaty clothes on the medical cart. Once in the medical area, I was attended to by a highly organized group of medical personnel involved with the race (only I could appreciate that fact in this moment). In the end, after having blood work done in the medical tent and after 3+ liters of IV did we discover that I had been dehydrated and suffering from a huge sodium deficiency. Unbelievable, that I had taken nearly 4000 mg of sodium on the bike and used snacks with sodium on the run and still was out! I knew that I was a heavy sweater and did need to monitor my electrolytes, but my gosh........sometimes the best laid plans don't even work.
The Conclusion
It has taken me awhile to put this together after thinking about this for most of the summer. Coming up short has affected me more than I would like to admit. However, in the end, Ironman is one of the most inspiring events you could ever attend or participate in. Though incredibly disappointed that I had to pull out, I am still grateful for what I learned in the process of preparing for and participating in this race. I was able to raise money for the I Will Foundation during my quest for the finish line and enjoyed representing them during the race. As I've told others, the race is not necessarily about total fitness. It is about knowing your limits, putting time into preparation, mentally preparing yourself for things that might go wrong over the course of a 12+hour race, and knowing the pacing you can handle. Even sitting in medical tent, I was inspired by others who I had raced beside throughout the day, whether they finished, or not. The commitment of the individuals participating, and the volunteers working the race are unbelievable. It is a test of preparation and will. Ironman Texas was going to be my only Ironman. But, for those that know me, I can never leave unfinished business. I will give it a go again in July 2013 in Lake Placid, NY.......this time, hopefully it will be cooler!
Until then, I will get back to my regular blogging.....many exciting topics on tap for 2012-2013!
Why Do It?
This is the question that is asked by all who don't. Any one of the three events of an Ironman is a daunting task. Many people would relish in specifically training for and completing a century bike ride or complete a marathon. Who in their right mind would want to do both in the same day and throw in a 2.4 mile open water swim to start for good measure, being allowed a maximum of 17 hours to complete the event? Surprisingly, more than you think. There are 30+ WTC sanctioned Ironman races per year worldwide. With an average of 2,000 people per race, there are nearly 60,000 people who attempt this feat yearly. Elite level (genetically freakish) professional triathletes complete the race in around 8 hours, but the heart and soul of the sport is the average age-grouper who holds a full-time job and has a family that completes this that fascinated me. I would watch it every year on TV and see video clips of the ends of these races and see these "average Joe's" accomplish this and say to myself "how is this possible?" Admittedly, athletically, I am not an endurance athlete by nature. I have always participated in events that were more anearobic in nature and excel in events that are more high intensity interval based in general (more later on how that affects your training). However, having enjoyed improved health and fitness by participating in shorter and mid-distance triathlons over the past few years, I decided to embark on a journey of trying to discover exactly how it is possible that this ultra-endurance event was being completed by people like myself. In essence, I decided to perform my own self-experiment in human exercise physiology, and approached the preparation for the event in this way.
Data, Data, and more Data
I am somewhat of a data geek on tracking issues involving sports health and performance, so I entered this project armed with a heart rate monitor/GPS device (tracking heart rate, pace, etc) for my running and a HR monitor coupled with a power meter on my bike for my training rides. I downloaded all information into TrainingPeaks.com and was utilizing their performance tracking software. I used this information only to track my progress and gauge the intensity and of the workouts. Training for endurance events is more about pacing and maintaining manageable levels of intensity (unless you are one of the aforementioned genetically freakish individuals that can race at a high intensity for 8+ hours). I thought is was particularly important to monitor my progress of fitness and body response to training to understand what levels of intensity I could work out at and keep my heart rate in a zone that would allow me to perform continuous exercise for 13+ hours. The data helped me to objectively track progress, but I avoided the dreaded "paralysis by analysis" of over-analyzing unnecessary information.
Obstacles Even Before Starting
What made this even more intriguing for me was to have several obstacles to try to overcome in preparation for this event.
1. A job that requires steady 60-80 hour work weeks. Time management was going to be important.
2. Bone-on-bone arthritis/condition of the knee. Two previous meniscus surgeries in one knee have left me with no cartilage on the medial side of the knee. This was also going to be an experiment on utilizing many of the medical therapies that I use on our athletes to see how manageable this was going to be. My orthopedic surgeon friends shook their heads when I told them what I was going to attempt.
3. Lack of heat acclimitization and opportunities to race. Winters in Iowa relegate most people to cycling on an indoor trainer and running indoors for the winter months. Spring weather is unpredictable and very windy in central Iowa. This was honestly my biggest known obstacle. I am a very heavy sweater even in mild conditions and have had issues with electrolyte imbalances and maintaining proper hydration levels as I have gotten older. My body has not typically responded well to sudden climate changes and exercise conditions. This was going to be a total crapshoot being that most of the training would be in Iowa and racing in Houston in mid-May could be pretty warm.
4. Never experienced exercising for an ultra-endurance event. I had no gauge as to how my body was going to respond not only to the environment, but to being exposed to exercise for that long of a time frame.
Most people say that the toughest part of the Ironman is getting to the starting line and surviving all of the training. I was armed with what I considered an above normal understanding of the above limitations and resources to monitor my progress, and I was convinced that I could come up with a plan to not only survive, but finish my first attempt at an Ironman.
The Preparation
The fall months were spent maintaining fitness in all three disciplines around a hectic college football schedule, but all-in-all, training went relatively well ranging from 7-10 hours per week of training. Full-on Ironman training started in the end of December (while we were at the Pinstripe Bowl) and I utilized a combination of training programs from various "experts" who are highly published. I constructed the program to meet and challenge my strengths, build my weaknesses, and timed to avoid injury problems (particularly controlling the amount of damage occuring to my arthritic left knee). In the end, over 24 weeks of training, I completed 97% of my scheduled workouts and distances. My swimming was the better than at any point in my nearly 4 years of triathlon. Biking was certainly different, concentrating on longer rides with less intensity (more on that later), and running was manageable. I had decided early on that for any runs that were going to be longer than 60 minutes, I was going to train with a popular method of running three minutes and walking 1 minute and did all endurance runs using that method. I planned on using that method for the entire run of the marathon for as long as I could hold out. I should mention that my longest competition run ever was 13.1 miles (done in a half-ironman in Kansas two years ago). It's funny that most people who know me from high school and college would remember my accomplishments as a runner on the track, but running has become my nemesis as I have gotten older. I admire people who run marathons, but you will never catch me signing up for one unless it is at the end of an Ironman. Typical training weeks were 8-14 hours with most of the endurance training being done on the weekends (too many 4+hour rides on the indoor trainer watching movies for my liking). In the end, I had dialed in what power levels I could hold on the bike for 6+hour of riding, was comfortable with the pace I could hold on the run for 2 1/2 hours, and was very confident in my swim. I had carefully monitored what my approximate fluid intake would need to be (measured how much fluids I was losing factoring in fluid intake on all long rides) along with nutritional needs to get to the marathon without "bonking". The only knowledge I had of the race course was a podcast I listened to by the people from Endurance Nation who had ridden the course and described (in very accurate detail) where the specific challenges of the bike course loomed. I had no "goal time" for this race. My one and only goal was to finish, but based on training times, I had a realistic shot at anywhere from 12 1/2 - 13 1/2 hours to complete the event.
The Pre-Race
I drove to Houston from Ames four days prior to the event (thanks to my father for riding along), checked in two days ahead of time at the mandatory check in (highly organized and very friendly people), and attended the athletes banquet. They say every person in an Ironman has a story, and this was an inspiring evening of speakers and Mike Reilly the voice of Ironman hosting. The day prior to the race involved checking in the bike and transition bags. I was able to meet current women's Ironman World Champion Chrissie Wellington (for a 2nd time) and listened to her speak about her new book "Life Without Limits" and had her sign a copy (I highly recommend this to athletes of both genders). It was the second time for me meeting her, and I will say that professional athletes from all sports could learn something from her. She is genuinely one of the most endearing people in sport.
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| Chrissie Wellington IM World Champion |
I typically get a little nervous before most of my events, but I was strangely calm before the start of this one. It was unbelievably inspiring to be out there with nearly 2,600 people. I was anxious to get the day started to see what was going to happen.
The Swim
If you have never seen the start of an Ironman race, it is one of the coolest spectacles in sport. Being in the mix, however, is even more of a spectacle. Starting a race in the water with 2,600 people at once is a little like trying to get out of a crowded pool if there was a shark attack.....it is chaos......and man, is it fun! This was taken from the bridge seconds after the start of the swim at the race. The huge group out in the water are those swimming without wetsuits, those using wetsuits started 10 minutes later. The IM Texas swim is kind of strange with an approximate .8 mile swim out into the lake, .8 mile swim returning to near the start, then a .8 mile swim up a canal on the left side of the picture to get to the bike transition area. The water was warm. Knowing that I have had trouble with overheating in warm water races in the past two years, I opted to not wear a wetsuit, but did wear a recently purchase Blue Seventy speed suit that was AWESOME! I started near the back of the pack giving myself a little room and trying to avoid congestion (I hate people swimming up on my legs). Within the first 800 meters, I had worked my way up to the pack and at the turn to come back felt pretty good. I was maintaining what I thought was a reasonable pace. I did have a moment of panic when I looked at my watch at the turnaround and misread the time (I thought I was on pace to finish 30 minute slower that what I anticipated at that point in the race, but didn't panic and just moved on). At the 1.6 mile mark, we hit the turn to swim up the canal, and by that point in the race, you are typically swimming with people your own speed, but I seemed to be passing quite a few people. The canal is approximately 20 yards wide, so it was destined to be congested with swimmers, and I tried to swim up the canal (which had several small "s" type curves in it) on the left hand side taking what appeared to be the shortest route. My hand started striking something that I assumed was another swimmer, but when I slowed up, found that I was actually hitting the bottom of the canal with my hand. I stood up and was only waist deep in the water and could see other swimmers on the right making good progress. I learned quickly to make any time in the water I needed to be in an area of the canal that had been dug out for tourist boats and moved over into a traffic line with other swimmers. The canal swim was very strange. Because of the huge number of swimmers making waves at once, the turbulence of the water was tremendous. There were so many side-to-side waves in the canal, it seemed as if we were swimming upstream (which was virtually possible, since there was no current in the canal). Regardless, I pulled in at the end of the swim only to be very surprised that I had misread my watch earlier, and had actually bettered what I thought would be a reasonable swim time for my first Ironman and got out of the water in a little over 1 hour and 10 minutes. I was not overly tired, and was thrilled with the start of my day. I decided I didn't need to be in any great hurry to get through transition (I wasn't really competing for a Kona spot) and decided to walk to pick up my transition bag and insure that my heart rate was in a very manageable spot. As I walked into the transition area, I noted that not many transition bags had been picked up in my age group and was thrilled to find out that I had finished in the top 20% of all swimmers and done very well in my age group. I picked up my transition bag, put on my cycling shoes, socks, and jersey (opting for a light weight cycling jersey over my traditional tri-racing top to battle effects from long exposure to the sun and remain cooler), grabbed my nutrition, took in a healthy amount of sports drink, and picked up the bike.........time to get my ride on!The Bike
The Transition
After talking to my sister briefly while I was moving through transition to get my running gear, I started to get pretty dizzy and didn't feel well. I had this happen on another occasion when I raced in temperatures over 100 degrees at the finish and ended up with an IV to recover. So, needless to say, I was concerned. Having not known exactly what the temperatures we were racing in, and considering I had tried to hydrate adequately throughout the bike, I was confused as to why I would be having these symptoms. At this point, I was only about 7 1/2 hours into the race and knew I had 9 1/2 hours to complete the marathon, so I decided to stay in transition until I started to feel better. I found a small area next to the changing tent in the shade, but was having a hard time cooling down and getting rid of my dizziness. There was virtually no breeze in the area and even in the shade I was having a hard time recovering. I normally am in transition about 3 minutes, but on this day, I camped out in there for about 45 minutes! After several bottles of water and cooling down, I started to feel better and headed out for the running course. Prior to leaving, I stopped by the medical tent and got a bottle of sports drink to try to replenish some calories and electrolytes, and was ready to take on the rest of what I knew would be a long run........
The Run
As I headed off on the run, I was planning on using my run 3 minutes, walk a minute strategy, but could only muster a 1 min run 1 min walk strategy due to some nagging cramping of the hamstrings. The IM Texas run course is an approximate 8 1/2 mile loop that is done three times. After walking/jogging (mostly walking) for the first 3-4 miles, I started to feel better and jogged until I started to have problems, then return to walking. This pattern continued for about the first 15 miles of the run. Since the loop ran through the woodlands canal area, I was able to see my wife and other relatives who were in the area on the run course several times. My wife had cut across the course and walked with me on a couple of occasions and she will never understand how important her support was at those points. I was very frustrated with my inability to sustain a run, but kept in mind the ultimate goal was the finish line. At about mile 15, I ran past a restaurant where another couple from Iowa who were there to do the race were (he had dropped out of the race due to heat earlier in the day) and I was encourage by them (they were both previous finishers and said I was looking great and only had one more lap to go). I really appreciated them at that point and moved on. At the end of the second loop I saw my wife and asked her to meet me at about mile 22 to do some walking. It was getting close to sundown and it was starting to finally cool off. I felt pretty good physically, but just felt exhausted and wanted to get through the last 8 miles. I still had about four hours to finish the race and felt it was well within my reach, I just needed to continue to be patient. The run course gets a little "curvy" when it heads out of the Woodlands, and with it now getting dark and with fewer competitors out there racing, I ended up getting a little confused and frustrated on the trails in the trees. At some point around mile 20, I decided I needed to take on more sports drink (I had only been drinking water and cola for the past 10 miles since my stomach was upset). As I entered the aid station, I asked a volunteer if I could take an entire bottle of sports drink to carry instead of a small cup that is normally used. The said "no problem" and I bent over the tub of ice where they were stored to get it. As I stood up, I knew I was in trouble. I became instantly dizzy and heart rate started to climb quickly (if you have ever stood up too quickly after lying down, think that x 10). I walked to the end of the aid station and felt it would be best to stop and sit for minute until things normalized. Unfortunately they didn't. In a strange set of circumstances in 90+ deg heat, I finally started to cool, but this time started cooling too much. What started as shivering advanced in to full fledge shaking which I couldn't control. Still having my senses, I was trying to determine if I was having a potassium problem or if I was suffering from further dehydration. I was prepared to deal with the dehydration, but was also growing concerned that a legitimate potassium problem was potentially dangerous. I still had over three hours to complete the last 6 miles and the medical personnel who had come by were leaving the decision of whether to continue to race up to me (they had learned what I do for a job and that made it pretty easy to communicate). After sitting there for roughly 20 minutes and symptoms worsening (rather than improving), I looked at my arm where I had written three key things for the race.....(1) only worry about things I could control, (2) be patient, it is a long day, and (3) family is my inspiration.
I promised my family that I wouldn't do anything stupid to try to complete this race (I have been known to be pretty stubborn when it comes to finishing physical activities) and as I sat there contemplating the cause of my significant inability to control my body temperature and the constant shaking that was occurring and worsening, I decided that I should withdraw from the race and truly live to race another day. It was painstakingly one of the most difficult and disappointing decisions I have ever had to make. I had signed up for this race, made a well-thought out program to complete this test and was planning on it being my only Ironman. The time sacrifices by both myself and my family over the course of the previous 10 months was pretty significant. However, without knowing the cause of my problems, I didn't think it was worth the risk to continue. Frustration and disappointment do not describe the moments following that decision. There I sat, 6 miles from the finish (only about 2 miles as the crow flies), able to hear Mike Reilly announcing the names of the finishers, and had to give in. I knew I was in need of medical attention. The outstanding medical personnel at the race attended to me right where I sat.One of the medical volunteers was a combat medic and inserted an IV into my arm right then and there.
Going to Medical
My biggest concern as I was being attended to was getting word to my wife and sister who would be waiting about two miles down the path for me to come through a final time. It was dark and I hate to worry her. She couldn't be reached on her cell phone (drained the battery doing race updates to all our friends and family), and I was worried that she would be worried. Regardless, they put me on a makeshift cot and onto a medical Gator and transported me to the medical tent. As I lay there crushed from disappointment I was simultaneously freezing from the open air wind in my sweaty clothes on the medical cart. Once in the medical area, I was attended to by a highly organized group of medical personnel involved with the race (only I could appreciate that fact in this moment). In the end, after having blood work done in the medical tent and after 3+ liters of IV did we discover that I had been dehydrated and suffering from a huge sodium deficiency. Unbelievable, that I had taken nearly 4000 mg of sodium on the bike and used snacks with sodium on the run and still was out! I knew that I was a heavy sweater and did need to monitor my electrolytes, but my gosh........sometimes the best laid plans don't even work.
The Conclusion
It has taken me awhile to put this together after thinking about this for most of the summer. Coming up short has affected me more than I would like to admit. However, in the end, Ironman is one of the most inspiring events you could ever attend or participate in. Though incredibly disappointed that I had to pull out, I am still grateful for what I learned in the process of preparing for and participating in this race. I was able to raise money for the I Will Foundation during my quest for the finish line and enjoyed representing them during the race. As I've told others, the race is not necessarily about total fitness. It is about knowing your limits, putting time into preparation, mentally preparing yourself for things that might go wrong over the course of a 12+hour race, and knowing the pacing you can handle. Even sitting in medical tent, I was inspired by others who I had raced beside throughout the day, whether they finished, or not. The commitment of the individuals participating, and the volunteers working the race are unbelievable. It is a test of preparation and will. Ironman Texas was going to be my only Ironman. But, for those that know me, I can never leave unfinished business. I will give it a go again in July 2013 in Lake Placid, NY.......this time, hopefully it will be cooler!
Until then, I will get back to my regular blogging.....many exciting topics on tap for 2012-2013!
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