Monday, April 14, 2014

Misadventures in Running Healthcare

Last Saturday I had a sudden, strange Achilles injury.  I've had trouble with tendinitis (or, as I guess it really should be called now, tendinopathy) in my Achilles several times in the past but have been able to keept the pain at bay with a program of eccentric heel-drop exercises.  Of course, it's hard to convince yourself to put in the time on injury prevention when you're not actually injured, so over the past year or so I've stopped doing the exercises.  I had about two days of general soreness before Saturday's run, and then when I was 20 minutes into the run, I felt a sudden pain and could no longer run.  It was hard enough just to walk the two miles or so back to the car.

I was pretty worried, since the sudden pain sounded a lot more like a partial tear (I did the calf squeeze test to check it wasn't a full tear and it wasn't) than "tendinitis."  And as I was recently saying to my friends Rasmus and Tracy, I wanted to know for sure which injury I was dealing with, because with a partial tear it's disputed whether running during the healing process is a good thing or a bad thing:  http://bjsm.bmj.com/content/38/5/597.full vs. http://jap.physiology.org/content/101/6/1720.full.  So if an MRI did show a tear, I would need to do more research, and probably be more careful, before I incorporated running into my rehab plan.

So, I went to the doctor...and I was dismayed at what I found.  Not at what I found in my tendon fortunately--that was good news.  It looks like there's no significant tearing.  The cause of the sudden pain may have been a muscle pull at the point where the Achilles meets the calf, or some combination of tendon microtears and muscle damage in that area.  What I was dismayed about finding was the quality of the advice I got.

I went to a sports medicine clinic.  One of their doctors, Dr. 2, was listed as specializing in Achilles injuries, so that's who I wanted to see.  On my first visit, Dr. 2 was out sick, so I saw Dr. 1.  I wasn't too bothered about who I saw for that first visit since all I needed was for someone to order an MRI.  But Dr. 1 was nevertheless an orthopedic doctor and so in theory should have had a reasonable knowledge of tendon injuries.  However, he didn't know what eccentric exercises were, despite their efficacy in tendinopathy treatment being shown by studies going all the way back to the mid-1980s and confirmed by higher-quality studies in the late 1990s (http://www.ncbi.nlm.nih.gov/pubmed/23669088 is a good general review).  Dr. 1 was also surprised by the idea of ultramarathons and suggested that I might have to choose between being injury-free and continuing to run long distances.  Dr. 1 didn't ask questions about the type of pain I felt when the injury happened or whether I had previously suffered from tendinitis--I eventually volunteered that information.

Dr. 1 did an ultrasound and thought he might see a partial tear, so he ordered an MRI.  A few days later I met with Dr. 2 to review the results.  As I mentioned above, he didn't see any significant tearing, so we started discussing rehab plans.  He asked whether I had been doing any PT/rehab yet and I said that after I found out the results of the MRI, I had started doing the standard eccentric heel-drop exercises.  His primary advice was that these were bad for tendon healing and that I should stop doing them.  Again, the evidence that these work is about as solid as it gets, e.g. http://www.ncbi.nlm.nih.gov/pubmed/11269583?dopt=Abstract, and the only cases where the exercises might not be as effective are when the tendinopathy is located at the insertion point in the heel or when the patient is not an athlete, neither of which are applicable here.  And of course in those cases the efficacy was only reduced; there was no suggestion that the exercises were harmful.

Dr. 2 also prescribed a (brand name...) prescription-strength anti-inflammatory.  This is unlikely to do me any good (http://www.ncbi.nlm.nih.gov/pubmed/?term=stovitz+robert+johnson and http://www.shoulderdoc.co.uk/documents/nsaids_tendinopathy_2006.pdf) and may in fact do some harm (http://www.ncbi.nlm.nih.gov/pubmed/3511134), not to mention the other standard side effects of NSAIDs.  And that is without even getting into the issues of (a) recent research showing that Achilles tendinopathy is not generally an inflammatory condition, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/, and (b) whether suppressing any inflammatory response is beneficial.

I am frustrated.  On one hand, I only went to the clinic for the MRI results, and I've successfully got those.  On the other hand, considering the high financial cost and time out of my day(s) that going to the clinic took, it would have been nice to get some accurate advice while I was there.  I will continue to design my own rehab plan based on real evidence, and I will keep a copy of the MRI images so that I can bring them for a second opinion if I'm having problems.  As it turns out, Hakan Alfredson, Mr. Achilles Tendon Expert himself, has a clinic in London, and I'll be in London at some point in the next couple of months.

When I left the clinic today, my question to myself was, what has to happen for this standard of treatment to improve?  And what can runners/other injured athletes do about it in the meantime?

I have no answer to the first question.  As to the second, beyond the advice that whenever my friend Dave finishes his injury prevention and treatment book, you should absolutely buy it--it focuses on climbing injuries but the general concepts are just as useful to runners as to climbers, and it is the best advice I've ever seen on injuries--I have two thoughts:

Stop assuming every doctor is equally qualified

Most countries have a longstanding cultural tradition of looking up to doctors and assuming that whatever a doctor says about your treatment must be right.  The problem is that when you stop to think about this, it's absolutely bizarre.  In every profession, there are people who are good at their jobs, people who are averagely competent, and people who are not good at their jobs.  To assume that doctors are somehow exempt from this phenomenon defies logic.  I have certainly seen in law that passing a bar exam is no guarantee of a competent lawyer--there's a reason that legal malpractice suits happen.  In a similar vein, passing medical board exams guarantees a level of base knowledge, and continuing education requirements guarantee additional learning in particular chosen topics.  Neither of those things guarantee that a doctor is current on the research in one particular area, that the doctor is good at interpreting and analyzing new developments in treatment, or that the doctor is good at collecting information from a patient and putting that information to use.

From the standpoint of an injured runner, the sooner the mindset of assuming every doctor is excellent at his or her job changes, the sooner treatment quality will progress.  A simple "Could you explain your reasoning for that?  I read a study which concluded the opposite..." could go a long way towards getting rid of treatment recommendations that are no longer supported by evidence but continue to be made simply because they always have been.  Today I was in a rush and didn't take the time to do this at my appointment, which I now regret.

Ask questions you already know the answer to

One problem for me, as an injured runner who's not in the medical field, is that it can be hard to tell if the medical advice I'm getting is good or bad.   I didn't come up with the most obvious solution to this problem until last year, and I still can't believe it took me 28 years of life to figure it out.  The solution is simply to ask questions you already know the answer to, and use the answers to those as a frame of reference for how seriously to take the answers to the questions you didn't know the answers to.  The way I see it, there are two correct answers to any question you can ask:

     -The actual answer, whether that's a black-and-white answer or an acknowledgement that the issue is a grey area and that there are competing possible answers.

     -A variation on the response, "I don't know, but I can find out for you."

These are equally good in my mind; where things go wrong is when you get an answer stated as a black-and-white answer which is factually incorrect, or an answer stated as a black-and-white answer where it is in fact a grey area.

I do understand that some injuries, particularly tendon injuries, are complex, that there are still a lot of unknowns about their causes and treatment, and that there is a healthy dose of voodoo in many of the treatments that are ultimately employed.  For example, I personally suspect that getting regular massage is the thing that cured by ITB problems, but I know the scientific evidence for this being possible is limited.  In other words, I'm willing to give an unproven treatment option a chance in some circumstances.  But what I experienced with my current injury was treatment recommendations that aren't simply unproven but that are in fact contrary to solid scientific research.  That's not good enough.

Monday, March 24, 2014

Bainbridge Half Marathon: The Unknown

Google Maps may have perfected its omniscience over much of the world, but it has only a tenuous grasp over Bainbridge, Georgia.  It led us astray when we were trying to find my race's packet pickup, attempted to take us 14 miles out of the way on the five-minute drive to our hotel, and declared the name of the road to our dinner restaurant to be "unknown."

This was apt, because for me a half marathon was also a big unknown.  I had run only one previously and that was 8 years ago, well before I started doing any serious training.  I had no idea how fast I should try to run or what kind of heart rate I could maintain for that distance.  I eventually decided to run by heart rate rather than pace and to stick with a heart rate of 170, about 5 beats per minute higher than I'd run a marathon at.

This worked out perfectly.  I felt strong and comfortable nearly the entire race (miles 10 and 11 were on the rough side though!) and it was possibly the most evenly-paced race I've ever ran:  I averaged 6:57 miles in the first half and 6:58 miles in the second half, for a new PR of 1:31.  I felt like I wasn't a million miles away from being able to keep up a slightly slower pace for a full marathon, although I'd have to get better at eating and drinking on the run--I would have liked to have taken a Gu at some point during the half but I couldn't figure out how to do that without wasting way too much time, so I just had a few sips of the coke that Divesh met me with at miles 6.5 and 10.5.

One quirk of being so bad at short distances is that all my short distance paces are virtually identical; I don't seem to have a fast gear.  So during the course of the Bainbridge half, I actually got 3 PRs:  5k, 10k, and half marathon!  I was so tempted to try for a mile PR during the last mile, but I knew it was going to be slightly uphill with lots of turns and I just couldn't force myself to bring on that much pain for so little chance of success.  Of course, now I'm kicking myself for that...

The race itself was a good event.  It was a small local race, not the kind you would usually travel for but I really wanted to do a half on this particular date to fit with my training schedule, and this was the closest flat option.  It was pretty well organized and everyone was so friendly; this was one of the best parts of the race for me.  I also liked the no-nonsense approach to the race goody bags:  the entire contents consisted of a race number, four safety pins, and two packets of ibuprofen.  What more does any runner really want?

 

On the way home the next day, we went for a run at Providence Canyon State Park.  I had seen it advertised as the "little Grand Canyon of Georgia" so that sounded like something we just had to check out.  It was a bit of a letdown since 99% of it was just your standard wooded forest scenery, but 1% of it was like this:


I was also very pleased to discover that my legs felt completely fine on the run.  They were definitely getting tired on the uphills, but they didn't feel injured, dead, or sore.  Onwards with another hard training week then...

Thursday, March 13, 2014

The verdict

Thanks for all the input on my race schedule dilemma.  I got some helpful comments on Facebook too, including:

----The AT section of JFK is a little crowded but not too bad.

----My friend Ed reeeeeaaally loves Telluride Mountain Run, maybe even as much as he loves pulling a sled though possibly not as much as he loves the beer mile.

I decided to go by process of elimination:

Maria said she would go out to Montana with me and do Run the Rut if I wait til next year, so that made it an easy choice to take that off the list for this year.

Le Grizz should, in theory, be a perfect option but I couldn't seem to get excited about it.  Also, I prefer my chances of surviving a race un-eaten by grizzly bears to be a bit closer to 100%.

I kind of want to run a road 100k next spring, which would be pretty similar to Door County in terms of distance/surface, so I eliminated Door County.

As Karen pointed out, TNF San Francisco can have major weather issues, and since that one is similar, in terms of what I want, to JFK, I'd put JFK slightly ahead of TNF on that basis. 

That left a seriously tough choice between Telluride, the Ultra Trail Serra de Montsant, and JFK.  While I was pretty tempted by Karen's suggestion of UTSM + winter road marathon, that would mean I'd have to commit to not doing a winter sled race...which would be tough.  I don't want to do Arrowhead next year but I'm still tempted by Susitna or maybe even White Mountains, if I could make it through the lottery.  

So, as much as I hate to leave the UTSM undone for yet another year, I think I'm going with JFK, assuming I can enter quickly enough to get in.  As an added bonus, two other GUTS runners might be interested in doing it too (one of them being a quietly super-fast previous JFK winner...).  Divesh took the news well that I had already volunteered him to crew for all three of us!

Since JFK isn't til November, I can maybe still fit in Telluride in August, although I would probably do it as more of a hard training run than a race so that the effect of racing at altitude doesn't take me out for too much of August training time.  It also leaves me time to try either a road marathon or the great local trail race Mystery Mountain Marathon in October.

Now I can get back to trying to get to grips with the Duncan Ridge Trail in time for Cruel Jewel...