Saturday, December 19, 2015

When it snows you notice those pigeon-toes

Intoeing: Part I

With all our climate change, there hasn't really been any serious snow yet (I know, now that I have written this, next week NYC will have a blizzard), so I have come up with the title for this much-anticipated blog post while flying at 30,000 feet over the Rockies, where there is indeed SNOW. Now, at long last, we discuss intoeing! 

As much as every parent worries that their child’s gate is not quite right or that they are constantly falling, intoeing in children, known as "pigeon-toes" is usually caused by a benign condition, and it is something that is usually without permanent sequelae. The most common causes of intoeing can be broken down by age.

Infancy (Birth to 1 year of age): Metatarsus Adductus

The National Library of Medicine
Fetuses have it rough. They have to figure out how to grow and develop while in the confines of the mother’s uterus. Sometimes the genetic material makes for a large fetus in a smaller sized uterus, resulting in metatarsus adductus. Infants of diabetic mothers are at risk for macrosomia (large size) and because of this, metatarsus adductus. It is not always size issues, however, sometimes it is just the position of how the fetus resides in the uterus. At any rate, many infants demonstrate metarasus adductus, medial (inward) deviation of the forefoot relative to the hindfoot. As long as it is flexible, there is no need for Orthopaedic referral. Flexible metatarsus adductus usually resolves on its own and does not require bracing, shoes, or splinting.

Reasons to refer –
Inflexible metarsus adductus is termed metatarsus varus because the bone proximal (closer to the head) is deviated medially (inwardly). This type is treated with serial casting and has good results when casting is begun very early. Therefore, pediatricians and neonatologists know to refer while the baby is in the newborn nursery or NICU for Orthopaedic evaluation in these cases.

Toddlers (1 to 3 years of age): Tibial Torsion
Netters Atlas of Anatomy

In children aged 1 to 3 years of age, the most common cause is tibial torsion. This means that the tibia, the weight-bearing bone of the lower leg is rotated so that the foot and knee are not properly aligned. Internal rotation (causing intoeing) is more common than external rotation (causing out-toeing). Tibial torsion can be unilateral or bilateral, but when it is unilateral, the left side is the more commonly affected side. Parents frequently report that there child is clumsy or trips often. Confirmation of the diagnosis is based on physical examination and measurement of the thigh-foot angle. This is performed by having the child relaxed and lying in prone position (on abdomen/front), with knee and ankle each at 90 degrees. An angle is measured between the line of the thigh and an imaginary line between the second toe to the middle of the heel. A thigh-foot angle greater than 10 degrees represents internal tibial torsion.

In the past, treatments such as splinting, shoe modifications, braces, and exercises were prescribed. However, these have been shown to be of no benefit and are no longer recommended. Tibial torsion rarely has long-term consequences, and it is not a risk factor for degenerative joint disease (arthritis). Rarely, surgery is used as treatment.

Reasons to Refer-

General pediatricians should refer to Orthopaedics for any children with severe internal tibial torsion (greater than 35 degrees of the thigh-foot angle). The normal tibial angle in older children and adults is 10-20 degrees of out-toeing. Children should be followed by their pediatricians at least annually to monitor the regression or lack of regression of intoeing. Greater than 15 degrees at age 5 is unlikely to spontaneous resolve and these children should be referred for surgical correction. The best age for surgical correction is 7-10 years of age.

Any child with external tibial torsion (out-toeing) who has gait disturbance or pain associated with the deformity should be referred to Orthopaedics because these may also need early surgery. External tibia torsion is concerning for cerebral palsy and other neuromuscular disorders.

Differential diagnosis-

-CP and neuromuscular disorders (external tibial torsion, pain, abnormal gait)
-Developmental dysplasia of the hip (limp, clicks on exam, possible leg length discrepancy, abnormal ultrasound)
Internal tibial torsion may cause awkward gait but never a limp. As my Pediatrics Chairman, Dr. Caspe always used to say during my residency, “A child with a limp has something,” meaning they have real pathology.

School-age: Femoral Anteversion

A very blurry Violet sitting in the W
position. I think she was clapping and
dancing, so I'm pretty sure this position
didn't last long!
This is the most common cause over the age of 3. Femoral anteversion is defined as anterior rotation of the femoral neck compared with the transcondylar axis of the knee and the long axis of the femur. This is a bilateral condition and is twice as common in girls as boys. It is often associated with sitting in the W position and the running gait of a child with this condition can be described as “egg-beater” or windmill” in appearance (the thighs medially rotate and the feet outwardly rotate). Femoral anteversion increases in severity until 5 years of age and then resolves on its own by age 10 to 12 and no treatment is required. No radiographic imaging is required for diagnosis or monitoring. Physical exam should include having the patient lie prone with knees flexed to 90 degrees and passively rotating the legs outward, causing the hips to rotate internally. Normal internal hip rotation is 35 to 50 degrees. Children with femoral anteversion have markedly increased internal hip rotation, i.e. 90 degrees. You may also note medial facing patellae while the child is in the standing position.

Happy Holidays, everyone! Violet says I
never stay long in the W position, Mommy!
Anecdotal but no scientific evidence shows that there may be an increased incidence of osteoarthritis of the hip and knee, slipped capital femoral epiphysis, and knee and patella instability in later years. If there is still some femoral anteversion but not enough for surgical correction, hip strengthening exercises can help encourage outward rotation of the femur to counterbalance the internal femoral torsion. Younger children may be more apt to do exercises in the form of games- have them walk backwards, climb the stairs backwards, or walk uphill backwards. Older children and teens can do more formal exercises such as wall squats, bridges, and hip abduction exercises. Also encourage children to avoid sitting in the W position.

Harris E. The intoeing child: etiology, prognosis, and current treatment options. Clin Podiatr Med Surg. 2013 Oct:30(4):531-65.
Li YH, Leong JC. Intoeing gait in children. Hong Kong Med J. 1999 Dec:5(4):360-366.
PREP Online 2013, 2015.

Stay tuned for Part II on Intoeing to see how these anatomical differences relate to athleticism. 

Thursday, October 22, 2015

How resolute were YOUR resolutions?

Violet wants to know how your
fall workouts are going. In this photo
we are on our way to the park for
a strength workout.
In January, everyone made resolutions about what they wanted to change or what they wanted to accomplish in 2015. Remember that? I also wrote a blog then about some tips for making sound resolutions, which you might remember or can revisit by going here. Sometimes it is easy to forget our highest aspirations as the winter drags on and then it is finally warm again and most of those nutrition goals go out the window with tailgating and barbecues and so forth, but maybe some of your fitness goals were easier to keep in the warmer sunshine. 

Well, folks, the days are getting shorter now, and the mornings are colder. Pretty soon it will be the darker and colder part of the year that makes many confine themselves to their couch with a blanket and some yummy snacks and hot cocoa. I’m not saying that there is anything wrong with that (love my cocoa!!!), but if you find yourself headed in that direction, maybe now is a good time to think back to those resolutions for 2015 and see where you are in accomplishing them. It is very easy to say that there isn’t enough time to accomplish anything in 2015, but you don’t want to let yourself go totally to the winds and make resolutions for 2016 even harder to accomplish. 

So, what were those resolutions? Did you write them down? You still have 2 ½ months to make something happen. If those were fitness or nutrition goals, I am here to tell you that you can definitely get something accomplished in as little as 6-8 weeks if you are motivated, so don’t give up, there is time left in 2015 to get the job done! Or at least to give yourself a head start on 2016.

Never too early to introduce your kids
to the importance of strength training.
My 2015 goals were pretty simple. After running throughout my pregnancy with Violet, I dealt with a lot of worsening knee issues because I hadn’t done enough strength training, so, in 2015, I wanted to make strength training a priority. With our Mommy-Babyworkouts, Violet and I were on the right track, but now my toddler wants to jump on me when I get out my foam roller (She thinks it’s funny, but I think she wants to go along for the ride, which makes balance a bit more complicated) or get on the floor to do abs. She doesn’t want to miss out on a single thing! She even tries to lift Mommy’s kettle bells…and ends up knocking them over onto the floor. Somehow we have managed to do 3-5 stroller runs a week and 3 strength-training sessions a week. Sometimes those are TRX workouts where she plays with toys and laughs at me as I do it, sometimes I manage to get in a solid kettle bell workout while she plays, and sometimes we take our resistance workouts to the park while she plays with wood chips or does “squats” with Mommy. Our squats are a deep squat with me holding her in front of me and then an upward overhead military like press where she sometimes gets a little toss and catch before going back down. She squeals with delight, which makes it all the more fun. Now it has gotten to the point where I say, “Violet, want to do squats with Mommy?” And she exclaims, “Yes!” Just as a disclaimer, be careful incorporating your kids into your workouts, though. Three concerns are (1) safety for your child, (2) maintaining proper form (for you- they don’t care what your technique is!), and (3) taking rest and getting good sets. Violet tends to want to do another set as soon as I put her down from doing one!

I know that this blog isn't info heavy, but I wanted to remind you not to forget your 2015 resolutions, and I also wanted to give some major shout-outs to families getting it done with their outdoor workouts over the summer and fall--

I have seen father-son tandem cyclists, a dad getting a serious run in while pushing a double stroller with his toddler and older child, and a dad running alongside his son who was using his scooter. Know the best part? All those on bikes and scooters had their helmets on, including parents! Way to go, outdoor workout enthusiasts! I am so proud!

But the winner of the season is the family to the left. When I asked this mother if I could take a picture and post it to my Sports blog, she said that I could and also explained to me what was going on. Her daughter had started out on the bike while mom was jogging behind the jogging stroller pushing her son. Then her daughter complained that she wasn't sweating enough and getting a good enough workout(!!!!!!!), so they switched! This little girl ran and pushed her younger brother while mom tried to ride the girl's bike. Go get 'em, ladies! Little bro has the bar set high for when he gets moving soon!

Are you feeling motivated? These other folks are making it happen, people!

On Deck - 

-Intoeing in Children (I have been promising this for a while, and it is coming!)
-Part 2 of Skin Problems in Athletes: Acne in Athletes
-Part 3 of Winter Fitness - How to Fall!
-Spine Health (I am not forgetting your request, Charles; this blog is gonna happen!)

Friday, July 31, 2015

The bit on trackers that make you fit

In true trifit tradition, the monthly blog is the very last day of the month! Because I took a hiatus from Fitbit land and entered Vivofit land, I figured I owed you guys a review on activity trackers, so here is the bit on trackers that keep/make you fit. Remember, they only work as well as you let them work. It's a gimmick that some people get tired of after a while, much like any other fitness fads. However, if you can keep it on and hold yourself to your steps and know what is good for you when you feel unmotivated and don't want to take an extra turn around the block to hit that step goal, then they work wonders, for anyone from the fitness enthusiast to the couch potato. It also helps if virtual peer pressure motivates you (i.e. the Fitbit leader board), and let's face it, in the era of social media, virtual peer pressure is what it's all about! You don't need a gym. You just need your phone app.


The skinny: great online interface, great following so many of your friends are probably on it, estimates stairs, tells more information about sleep/wake cycles than other trackers, maybe not so great in terms of accuracy as a tracker

So many of these aren’t the best pedometers. Wrist-worn accelerometers (what activity trackers are) aren’t as accurate as the clip-on accelerometers that function more like pedometers; the wrist-wearables tend to overestimate steps. So, if accuracy is your thing, you are better off buying the Fitbit Zip (If you want something simple) or the Fitbit One (if you also want it to tell you about your sleep like the other higher-up wrist-worn Fitbits), since these are not wrist-worn. But, if challenging yourself to get more and more steps each day and being at the top of your Fitbit Friends list is your thing, get the Fitbit Charge. The Fitbit Flex is more affordable, but the Charge has a nice display, telling you the time and all the other fun info like steps, calories, stairs, so you don’t have to wait until it syncs with your phone app to have that information. And it can be a watch and not just a bracelet. The Charge HR is nice if you want to know your heart rate all the time, but it’s not as accurate as a heart rate chest strap monitor, which isn’t that surprising. The Surge has GPS tracking. I see this as the wanna-be workout watch, sorry folks who have this. (Leah, I think you have one. Sorry? I really think you would like the Garmin Vivoactive more because it also does golf and cycling!) If you want a GPS watch, you have to go with Garmin, the people who have been doing GPS for multiple sports for the longest amount of time. But I can see the appeal of having your steps and your workout watch be the same thing. As a triathlete, I would rather have the Garmin 920XT because it works for swimming, biking, and running. But I am waiting for someone to get me that for Christmas. (HINT HINT) If you just want to track your running, and you don’t mind wearing a bigger watch all the time, then the Surge works for that and keeps everything in one watch. If you’re into more than running, then Garmin also makes another watch that’s great, the VivoActive, which I will talk about later.
Even Violet agrees the chest-strap heart rate
monitors are better. By the way, I didn't  ask
her to do this pose. Our daughter likes going
to get my bag of tri goodies when we are
about to head out for a stroller run. And today
she thought she'd try out the heart rate monitor.
I didn't even tell her I was doing this blog.
Oh, Violet, you are so amazing!

Come on, Nike. The battery life is pretty awful. Fitbit lasts a good 7-10 days, depending on how active you are, but Nike Fuelband lasts 3-4 days at best. It doesn’t track steps. It tracks activity and you earn "fuel" on a kind of points system. Nike has to be different. I just don’t have a lot to say about this watch. It’s not as cool as Fitbit, sorry.

Does all the stuff Fitbit does (steps, calories, sleep, etc.), but from what users tell me, it has had more problems. The band is really cute and dainty and can pass as jewelry, but for some people it comes off in the most inopportune times because it doesn’t actually clasp, it overlaps. I was pretty much obsessed with the UP3 coming out before I bought any activity tracker, and my husband thought better of it and didn't get it for me because he knew that Fitbit was the better band. Good looking out, Curtis. They may be getting better, but I think they're still behind Fitbit and Garmin. The UP3 does do resting heart rate, just like the Fitbit Charge HR, and it is much sleeker and prettier looking, if that's your overall goal.

The Skinny: nice watch, water-proof, never needs charging (battery replacement at one year), but gives less sleep info, no stair counts, and the app could use a little help

Vivofit 1 and 2 – I bought the Vivofit2 because I am doing a research project with it and feel like it’s a good investment to use what the subjects are using, so we are all on the same page J Also this was a good excuse to try out another activity tracker. So far, I definitely LOVE it. It’s sleeker than the Fitbit Charge, and I like the “button” that you use, as opposed to the side button on the Charge. It also displays the time (or steps or calories, whatever you preference, to be chosen in the settings) all the time; you don’t have to press the button to see it. I find this great because it makes it more like a regular watch, which is how I use it. It’s also water resistant to 50 meters (basically waterproof, as far as I’m concerned), which is a huge plus over the Fitbit, which is not. It also has a year-long battery life because it uses a replaceable watch battery, so you don’t have to charge it. This is similar to the Fitbit Zip (6-month battery) and Fitibit One, but the Vivofit is a wrist-worn tracker, so that’s one-up for Garmin. You can wear it swimming, and it counts your “steps.” I think this is a major plus, but that’s just me. But you also don’t have to take it off to shower, like you do the Fitbit wrist-wearables. And it has a very secure clasp. My Fitbit would come off accidentally sometimes, but this has a lock on the clasp, so it stays on. Amazing!

You can see this as a pro or a con, but the Garmin Vivofit calculates step goals for you. This is great for someone who isn't going to hit the recommended 10k steps a day right off the bat. It gradually increases your goal for the day, based on how you have been doing. I find this awesome because it encourages you to improve, no matter what level you are at, but I do miss the vibration and party of the Fitbit when you hit 10k steps. It would be nice if these trackers allowed you to set your own goal, but Garmin is onto something with this proposed goal thing.

The cons include that the Vivofit, didn't work as well when running with the jogging stroller because my arm wasn't moving as much. With the Fitbit, it didn't seem to matter if I ran with or without the jogger, but again, the Fitbit does overestimate steps a bit. The other major con is really that the Garmin Connect app just isn’t as cool as the Fitbit app. That is the bottom line. And maybe most of your friends are Fitbit wearers and not on Connect. There are a few programs that sync activities from Garmin Connect to the Fitbit app, but they only sync activities, not total steps. So, you can choose watch vs. friends list or you can wear a Fitbit Zip to have your bells and whistles dashboard that you like and your friends list but wear the Vivofit as your watch and wrist-worn accelerometer.

I think the verdict is still out on whether I like the Vivofit over the Charge. I prefer the Vivofit as a wearable. The waterproof feature and year-long battery are major, major pluses for me, and I like having all my workouts in one place, so on the Connect webpage I see my triathlon workouts and my Vivofit steps. But Fitbit works with my jogging stroller and estimates stairs (although often widely inaccurate in doing so, it's nice having that extra motivation).

Both Garmin and Fitbit also sync with MyFitnessPal, by the way, which is awesome, if you use that app. Fitbit may lend to you eating more calories than you should. I definitely lost weight exercising less but eating better with my Garmin, since it only transferred over "active calories" (calories burned during an activity) and not all those 18k steps I did throughout the day that weren't as active. But Fitbit makes you feel better about yourself haha. Such a tough call!

Vivoactive –

The Skinny: the best multisport, activity-tracker watch on the market; maybe it doesn't matter if you don't like the app because your watch is so awesome...but you still might miss your Fitbit dashboard.

One last plug for Garmin. The Vivoactive would be my solution to the issues with accuracy in the Vivofit, since this is a GPS watch. It's the do-it-all watch comparable to the Fitbit Surge (but better, in my book). For the running, stepping, cycling, and swimming enthusiast, this watch does it all! You can download golf courses to it and do all the stuff that those golf GPS gadgets do, but this is on your watch. It can count your strokes in the pool and your laps and all that fun stuff. It does GPS for running, so here you have your GPS watch. For cycling, it does everything a tri watch will do, especially if you add the cadence sensor to your bike. So, yes, it is pretty amazing, and it’s sleek and cool looking. However, the battery life is not for an Ironman athlete, at least not for an age-grouper like me, since it only lasts 10 hours in GPS-mode. Oh well. Still pretty awesome! This is the watch I would want if it wasn't half the cost of the 920XT. For the money, I'd rather just use my Fitbit of Vivofit for day-to-day use and then spend the extra dollars on getting my high-end Ironman watch. But I'm a little nuts. For most folks, the Vivoactive is the watch to buy! Will let you know if I try it out.

The bottom line:

I hope this has been somewhat helpful for anyone considering an activity tracker. Fitbit and Garmin are definitely the best options. The Fitbit Flex is a great, less expensive way to go for a wrist-wearable, if you don’t mind looking at your phone app, and the Zip and One are great and more accurate, if you don't need a wrist-wearable. If charging and remembering to take off your watch for water activities are going to be an issue for you, then you need the Vivofit. You might also consider this if you are just starting out, might get easily discouraged, and need a goal closer to your usual activity than 10k steps a day. If you want your workout watch and daily step tracker all in one, go for the Vivoactive. Hope this helps, folks! Now, get out there and get moving!

Diaz, KM, et al. Fitbit: An accurate and reliable device for wireless physical activity tracking. Int J. Cardiol. 2015 Mar 4;185:138-140.

On Deck:

-Resolution update, life decisions, and some cute Violet pics!

Friday, June 5, 2015

Jogging Stroller Safety Update!

Eight months ago I wrote a post on jogging stroller safety and changes in running mechanics. At that point, Violet was not old enough to ride in a jogging stroller due to her developmental stage. Babies should be at least 6 to 9 months and able to sit upright with good tone before you place them in a jogging stroller. They should be secured similarly to the way they are in a car seat, with a 5-point harness. It is best to buy a jogging stroller for running with your child, since regular strollers do not have the support, padding, and stability that jogging strollers do. For more specific tips, please see the full blog post here. And, read on for the jogging stroller update, as promised!

Since writing my first blog on this topic, I researched many strollers and decided on the Bob Revolution SE because it seemed like the best fit for us. It has an adjustable handle, a swivel and lock front wheel, internal pockets for toys/keys/water, a nice canopy, and, too boot, it's easy to fold up and transport. Read on for details on why this stroller is our favorite:

*Adjustable handle - nice for people who are runners of different heights, but not such a big deal for my husband and I, as we are both tall 

Violet got this nifty tracksuit which
is great for workouts, especially
the rainy runs we did this week. I told her
we were putting this photo on the blog,
so she wanted to say hi to all of Mommy's
readers. Notice how the wheel in this
photo is not locked in the front position yet.
*Swivel and lock front wheel - I highly recommend this for anyone who thinks they will use their stroller for the occasional walk in addition to running. We bought a "Snap n Go" type stroller when Violet was a baby because snapping the car seat directly into the stroller seemed like the way to go. I never really used the stroller because I was in love with the Ergo carrier and going for cuddly walks with my girl, but my mother-in-law loved the car-seat-stroller combo,and it was light-weight and easily portable. We still haven't bought another stroller for our growing, almost-13-month-old because the jogging stroller duels as both a walking and a jogging device. The front wheel of the Bob Revolution enables us to lock it for straight-forward running which provides greater stability, and then as soon as we are done with our run, we unlock it, and the swivel wheel is easily maneuverable for getting the stroller back into the elevator and apartment. Perfect! For this reason, it is a nice feature, even if you're not planning to use your jogging stroller for your everyday stroller; it just makes it easier to get your jogging stroller to and from wherever you are doing your jog!

*Pockets that fit sippy cups or toys perfectly - maybe you have certain things that you need during your run, so does your child! During our first longer run with Violet, she slept some but woke up after about 45 minutes, downed an entire sippy cup of water, and then kicked back and enjoyed the rest of the ride. Older kids may need a break during the middle of your run to run around and play themselves, and they may need toys. Hydration and snacks are important for you and your child for the longer distances.

Running for the weather. Remember- you
are not the only one who needs to choose
running gear wisely. In general, baby needs one
more extra layer than what you would wear if
sitting and not active in the outdoor climate. For a
stroller jog, also consider wind and sun exposure.
*Canopy - protects your child from the elements! Violet has very long legs, so I always make sure she has pants
or sunscreen covering her from the sun, but then earlier this week we did a few rainy runs, and the canopy worked great for that as well! I was reluctant to take her out at first, and we tried to run during the periods of the day without rain, but inevitably got caught in some drizzle. The canopy kept her dry except for just some light drops on her legs, so you can run rain or shine to a certain extent. No lightning and no crazy thunderstorms, thank you! 

*NAPS! - My husband calls our jogging stroller, "The Enterprise," because he says that Violet wants him to go "warp speed." I call it the "dream sleeper" because Violet falls asleep in it within 15-20 minutes of running. Lately she will continue her nap at home when we return, under the nice shade of the canopy. Then Mommy has time to lift weights and shower! Some days this is the only way we get a nap, and she wakes up so happy, so I am always thankful to the stroller for our Mommy-baby running time and our baby nap time!

Our girl holding Mommy's and Daddy's
medals. The least we could do since she
trained every weekend with us but didn't
get to go in the race on the big day.
I can't say enough great stuff about this stroller. We trained for the Indianapolis 500 Mini Marathon, and Violet did every single long run with us, having a ball with her Daddy going warp speed! We were sad that we didn't get to bring her with us for the race, but strollers aren't allowed for the Mini. As in the previous blog, always remember to check with your race directors to see if strollers are allowed. Sometimes they are! 

More Info:

Runner's World Review of Jogging Strollers -

Thursday, May 7, 2015

Got Shin Splints? The Low-down on MTSS...

Recently a friend/colleague of mine asked me what she could do about her shin pain. She says that every time she goes for long walks, especially hiking, she develops anterior shin pain. After giving her the quick rundown on what to do, I decided maybe it was time for a blog on medial tibial stress syndrome.

What is it?

Medial tibial stress syndrome is commonly known as shin splints. It is one of the most common causes of exertional leg pain in athletes. MTSS is on the spectrum of repetitive stress injury that ranges from shin splints to actual stress fracture of the tibia (the weight-bearing bone of the lower leg). Stress reaction in the tibia and surrounding musculature results because the body does not have time to heal due to repetitive trauma of the tibia and surrounding musculature. Without rest and proper treatment, this can progress to stress fractures of the tibia.

Pathophysiology – what’s going on in there?

Thought initially to be due to underlying periostitis of the tibia (bone injury), MTSS is now thought to be a spectrum of tibial stress injuries including tendinopathy (when tendons that attached muscle to bone become inflamed), periostitis (inflammation of the periosteum, the outer layer of bone), periosteal remodeling (when bone breaks down and rebuilds), and stress reaction of the tibia. It is also thought to be due to dysfunction of the muscles in the lower limb- the tibialis posterior, tibilais anterior, and soleus muscles.

Physical Exam

For the medical providers out there, on physical exam, the medial ridge of the tibia (origin of the tibialis posterior and soleus muscles) is often tender to palpation, especially at the distal and middle tibial regions. The anterior tibia, however, is usually non-tender. Reassuringly, neurovascular symptoms are usually absent. Sensory or motor loss with associated exertional lower leg pain is more indicative of a diagnosis of acute or chronic exertional compartment syndrome. While ECS can be confused with MTSS, it is different in pathophysiology, diagnosis, and treatment. (Maybe that can be another blog!) 

A thorough musculoskeletal exam should be done to evaluate for associated abnormalities of MTSS including genu varus or valgus, tibial torsion, femoral anteversion, foot arch abnormalities, or leg-length discrepancy. All of these can affect stress on the tibia. Leg-length discrepancy can be evaluated by multiple methods, however, the simplest may be having the patient lie in supine position and evaluating the symmetry (or asymmetry) of the medial malleoli. Also examine flexibility and balance of hamstrings and quadriceps muscles as imbalances and poor flexibility can be associated with lower-extremity stress reaction. These can be a focus for preventative exercises during the treatment phase.

One of the most common risk factors for MTSS is hyperpronataion of the subtalar joint, caused by poor ankle mobility at the tibiofibular joint or limited ankle dorsiflexion. Assess for this by viewing the feet in standing position as below. You can also have the patient perform a one-legged squat in standing position or you can do a gait exam as these can bring out worsening hyperpronation.
Subtalar hyperpronation on (a) medial and (b) anterior view.

Further Work-up

This is usually not indicated, but if the athlete is not improving after conservative treatment (see below), imaging can be done. X-rays typically do not show pathology until 2-3 weeks after initial injury. At this point, you may see periosteal exostoses if the cause is related to periosteal reaction. This is also a time to identify any healing stress fractures that may have been the cause of the pain. MRI can show changes much earlier than 2-3 weeks, demonstrating progression of injury in the tibia, starting with periosteal edema, progressive marrow involvement, and finally cortical stress fracture.

Initial Treatment

MTSS just happens to be one of those nagging injuries that keeps us from doing what we want to do, so many times people ignore their pain, but if you are having pain for more than a week, you should go to your Sports Medicine Physician for an evaluation to ensure that you do not have stress fractures, a more severe complication of medial tibial stress syndrome. Rest, ice, NSAIDs (non-steroidal anti-inflammatories such as ibuprofen), and calf stretching for initial pain symptoms is the first-line treatment. Since initial treatment is what no athlete wants to hear (rest, ice, ibuprofen), modifying the training program to decrease intensity, frequency, and duration of work-outs can be done when full rest is not possible. Decreasing mileage by 50% can help alleviate symptoms without complete cessation of running. Avoiding running on uneven surfaces and on hills is also recommended. When beginning rehabilitation, low-impact and cross-training exercises should be done, in addition to strength and flexibility exercises.


Fit Feet 
My daughter now owns Stride Rite shoes.
They provide the proper amount of support
for this little lady who is about to go off
exploring the world all on her own two feet.

As we discussed earlier, hyperpronation at the subtalar joint is one of the main risk factors for MTSS.
Orthotics can be helpful to correct this. Another important thing to consider is footwear. Shoes with shock absorbing soles help reduce forces through the lower extremity and prevent repeat MTSS. Shoes should also have the proper fit and be changed every 300 miles to 6 months of wear. Runners who train in extreme climates should consider multiple pairs of shoes to keep on rotation as wet shoes lose 40% of their shock absorbing and support capabilities.

It’s all in the kinetics

An assessment by your Sports Medicine Physician, Physical Therapist, or Strength & Conditioning Coach certified in Functional Movement Screening can help pinpoint abnormalities in kinetic chain movements and help correct these with exercises.

Specific strength and flexibility exercises
These are for after an initial rest or modified training phase; do not attempt in the acute phase as this can exacerbate symptoms.

Proper footwear is even more
important on uneven terrain!
Stretching and strengthening of the calf muscles, including eccentric calf exercises (up with two legs and down with one on your heel raise, or can go up with non-affected leg and down slowly with affected leg) can prevent muscle fatigue and prevent MTSS. Strengthening of the tibialis anterior and other muscles that control foot inversion and eversion may also be beneficial as these provide increased ankle and foot stability.
Ankle ROM and strength exercises with Thera-Band.

Core hip flexibility and strength are related to almost every injury in Sports Medicine, and MTSS is no different. Thus, strengthening abdominal, gluteal, and hip muscles (See the Mommy-Baby Core Workout from 2014.) can improve running and gait mechanics, thus preventing lower-extremity overuse injuries like MTSS.

Medical treatment

ESWT, extracorporeal shockwave therapy has been shown to be beneficial in some studies; ask your doctor about it! Injections with cortisone, dry-needling, and acupuncture have been used for treatment of MTSS, but there are no conclusive studies proving these treatments work specifically for MTSS.

Surgical treatment

A posterior fasciotomy can be performed in athletes who do not improve with the above measures, and intramedullary nail placement can be done for stress fractures in season. However, these procedures may not be curative and are not the most common treatments. They may improve pain and function, but results vary among individuals.


This is the most important step. Athletes who suffer from MTSS are at high risk for repeat injury. Training errors, poor technique, and abnormal anatomic alignment should be fixed, and focus should be on the strength and flexibility exercises above. If you are having repeat episodes, it is important to have a thorough evaluation and an individualized training/rehab program.


Beck B. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med. 1998;26(4):265–79.
Galbraith R. and Lavallee M. E. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med (2009) 2:127–133
Moen, Rayer, et al. Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. Br J Sports Med. 2012 Mar;46(4):253-7.
Sems A, Dimeff R, Iannotti J. Extracorporeal shock wave therapy in the treatment of chronic tendinopathies. J Am Acad Orthop Surg. 2006;14(4):195–204.
Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am. 2006;17(3):537–52.
Wilder R, Seth S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23:55–81.

On Deck:
-Jogging Stroller Safety Update
-Acne in Athletes, Part 2 of Skin Problems in Athletes

Friday, April 3, 2015

Fun, Fit, and Frugal!

I recently saw a clinic patient of mine who is a morbidly obese 11-year-old girl, and I spent the entire follow-up visit trying to find what would motivate her and make her find ways to stay active. I felt sure that if we could find something she liked and wanted to do, then we could get her feeling better about herself and also help her make healthier eating choices...only to find out later that what she really likes doing is playing and running outside with her friends, but she doesn't get to do this because her mother who is a single parent of 3, does not get home until very late each night, and doesn't want her children outside by themselves. I had the mom leave the room, so I could talk to my patient about body image and ask if she had ever felt like hurting herself because of the way she feels about how she looks. She had. My heart went out to her. 

I really connected with this particular patient who I have followed during my residency training at Jacobi. But, sadly, this is not an uncommon story in the Bronx, where finding ways to stay active and healthy are made more difficult by living in neighborhoods where it may not be safe to go outside for a walk or run, by having parents who may or may not be involved or supportive, by having family medical problems that put children at risk for early-onset diabetes and high cholesterol, and by having low income and poor access to healthy foods. Fast foods and junk foods are just cheaper and easier for these families.

So, in honor of my patient, a short blog on ways to stay fit that are fun and frugal. I think we could all take a little away from this, and it's my hope that all of us who are more fortunate and have money but not the time or time but not the money, can be thankful for what we have and use those 20-30 minutes each day that we don't think are enough and do something healthy for ourselves and for our families.

1. FAMILY FITNESS -    Maybe your gym doesn't allow you to bring your kids. I had a parent tell me this this week. She was going to the gym after work while her child was staying home, inside, doing nothing, and the excuse was the gym didn't let children under age 18 enter. Well, my advise to you - Find another gym! YMCAs are great examples of places that prioritize family fitness and have classes and sports just for kids. Other gyms may even have childcare for your younger kids, so they can play while the rest of the family gets their workout on. Don't live near these places? Then find a freaking park. Yesterday I finished clinic early enough to go for a run, but I also really wanted to go see Violet. I thought about going for a jogging stroller run with her (an update on that later!), but instead, my husband and I went for a walk with her. Maybe only in the Northeast can you appreciate the first real day that feels like spring and how wonderful it is to go for a family walk, but I'm telling you, even walking in the snow with this girl this winter was so much fun. The least expensive fit thing you can do as a family is go for a walk. A run is even better, but walking is for everyone! A brisk walk lifts your mood, helps you add more active minutes to your day, and the endorphins from that may even make you happier later and make healthier eating choices. Voila Bon appetit.
snow walk with my girl!

2. FAD FITNESS – I usually don’t condone fad fitness stuff, but, hey, if this is what you need to stay active, go for it! Zumba, Piloga, Crossfit, you name it, do your thing. Can’t afford fancy fitness watches or heart rate monitors? You don’t need them. If tracking steps is your thing, buy a cheap pedometer and write down your total steps at the end of each day. It’s a great way to see how active (or not active) you are and use that to motivate yourself to go for that walk or run at the end of the day when you feel like you don’t have time or energy or whatever other excuse you want to make for yourself. Your phone might even have a pedometer app. Samsung Health is one example. There are also these really cute and inexpensive fitness watches for kids – check out Leapfrog. Marketed for pre-school age, it has games for kids and fun ways to stay active. There are also inexpensive versions of Fitbit.

3. FEELING GOOD – Do what makes you happy. Dance, jumping jacks, soccer, cycling, swimming (you’re right, you do need a body of water for that
Buying a soccer ball is really
not that expensive if you think
about the opportunities it gives
you to stay fit! (start early)
one), walking, push-ups, weights. Your child only wants to play video games? Great! Check out Dance Dance Revolution and other Wii Fit games. There is definitely something out there for you, and the more you like doing it, the more likely you are to keep up with your 

4. FREE ONLINE PROGRAMS – Popular fitness trainer workouts on YouTube

Better U  - from the American Heart Association, this program is a 12-week educational program about health, nutrition, and exercise, and it’s free! They also have healthy recipes on their website.

LoseIt and Myfitnesspal – free online calorie and exercise tracking – more about fitness but there are nutrition tips too, also a good workout online tracker

Dailyburn – costs money after 30 days but has workouts from kettle bells to dance to yoga and – I always recommend these to my pre-adolescent and adolescent patients. There is an exercise and nutrition section among other health and medical topics of interest to teens.

There are a million more. Google is your friend, folks.

5. FREE AT HOME – Sometimes the oldies but goodies are the least expensive and provide the easiest accessibility. Jump rope, hula-hoop, dance videos, exercise videos. These are all things you can do in your home with very little equipment. Even a 20-minute exercise video, if you can do it each day, is a step in the right direction. Don’t like any of these, I stand by my tried and true stay-active method – DANCE. Ask anyone, I have the least rhythm and coordination of any athlete on the planet, but dancing with my daughter in our apartment makes us both SO happy. Find your music, find a friend or find 30 minutes and get down with your silly jazzy self. There’s no way you won’t feel better and no way you won’t burn more calories than you would sitting on the couch with a sleeve of Oreos. Too lazy or don’t have time to make your own playlist? Try Spotify and use other people’s playlists or again your friend, YouTube for a 30-minute aerobic dance workout

On deck:
Jogging stroller update!

Saturday, February 28, 2015

Skin Problems in Athletes

It was zero-degrees-Farenheit and -17-degrees-Celsius this morning. What better day to talk about how winter weather can affect the skin…

Miss Rosy Cheeks :)
Over the last month, my daughter has had the cutest rosy cheeks, and my hands and face have been getting cracked and dry, battling worsening winter eczema. Cold weather, especially for outdoor athletes, makes skincare even more important. I thought of writing this blog last month when we were just entering the harsher winter weather, and I had forgotten my facial moisturizer for a run but contemplated returning home during the first mile for my face mask because my face was stinging in the wind. With weather like that, you start to think about skin problems in athletes, and voila this beautiful blog was born! For related tips on winter outdoor training and gear, please see last January's blogs: winter training and gear.


What is it and what causes it?

Eczema is a dry skin rash caused by defects in skin barrier function, immune abnormalities, and environmental and infectious agents. The immunologic abnormalities and the skin barrier are genetic and related to problems with filagrin, a structural protein that helps the skin barrier hold in moisture. The only reason I tell you all this medical mumbo-jumbo is because it shows the importance of fragrance-free emollient use for the treatment of eczema- you need to help your skin replenish the moisture that it is constantly losing because it has no filagrin to help keep the skin barrier intact and hold in the skin’s moisture. One of the other issues with atopic (allergic) skin is deficient in stratum corneum lipids (fats in a particular layer of the skin) such as ceramide, which is why using lotionss with ceramide such as CeraVe can help. Fragrant perfumes and dyes can further irritate skin, especially atopic or eczematous skin, so it is important to choose emollients that do not have these additives.

What to do?

Swimmers – Swimmers are especially at risk due to continued submerging in water as well as chlorine’s chemical irritation of the skin. It’s important to take a quick shower after the pool to rinse off any chlorine and to apply fragrance-free emollients (Aquaphor, Cetaphil, Eucerin, Vaseline) to skin that is still moist after showering in order to lock in the moisture and protect skin. Then reapply 3-4 times per day to the driest areas.

Outdoor athletes – Winter, wind, sun can really affect skin. Always apply sunscreen prior to outdoor workouts (go here for a nice rundown on how sun exposure affects skin). In the winter, we often skip the sunscreen hoping to get our daily dose of Vitamin D, as sunlight allows the skin to produce vitamin D; however, in doing so, you are probably missing out on an emollient that you don’t even think about. Moisturizers with sunscreen are first and foremost moisturizers. I always wear facial moisturizer while running (a small amount of water-based moisturizer helps protect the skin from the wind without causing breakouts- look for noncomedogenic moisturizers), and I usually put Aquaphor on my hands underneath my gloves or longer shirt that I pull over my hands to keep them warm. It’s like a mini-hand treatment while running since you are moisturizing and then heating up your hands as you vasoconstrict your peripheral body during your workout, so instead of having hands exposed to cold weather getting dried out, frozen, and chaffed, they are actually benefiting from a moisturizing treatment. Try it and see what you think! When you come in from your cold workouts, avoid long hot showers. Longer water exposure and hot water exposure can dry out the skin even more. Stick to a short, moderately warm shower, and apply your emollient of choice to moist skin after showering to lock in moisture and give skin back the natural barrier it is missing. Protecting your skin from the wind while outside and not over-drying it with long, hot showers while inside can work wonders for your eczema.

Tinea / dermatophyte infections

You can see why tinea corporis is called ring worm!
Photo credit: Uptodate (Yes, I used Uptodate, don't judge).
Tinea capitis, black dot tinea type, with surrounding alopecia.
Tinea corporis (ring worm), tinea capitis (scalp ringworm), and tinea unguium (fungal infection of the nails, a.k.a. onychomycosis) affect many athletes. Athletes are at risk for tinea corporis and tinea capitis due to excessive sweating that produces humid conditions on the skin. Typical sports are wrestling, rugby, and soccer, due to the close contact in these sports. Good hygiene (showering after practice and games, ensuring that feet are dry when placed in clean socks, etc.) can prevent transmission of these infections. Tinea corporis and tinea cruris (“jock itch”) can be treated with topical clotrimazole or other over-the-counter antifungal creams for 2-3 weeks. Rash may resolve after 1-2 weeks but another week of treatment ensures eradication of the infection. If infection is not improved, oral treatment with terbinifine or fluconazole is recommended and requires a prescription from your physician. Tinea capitis causes ring worm on the scalp, which can look like a scaly, red plaque that may not be noticed until it results in surrounding hair loss (alopecia). This infection can be very, very difficult to eradicate, especially in younger children, and it can persist indefinitely and lead to permanent hair loss if not treated. Treatment is with oral griseofulvin for 8 weeks, which is difficult for children and parents, especially since it must be taken twice daily and must be taken with high-fat containing foods for best absorption. Terbinafine is a similar medication which is approved for adults and only requires 4 weeks of treatment. Other members of the household are often asymptomatic carriers of the disease, including pets! Family members should be cultured by their physicians and treated with ketoconazole 2% or selenium sulfide 2.5% (Selsun Blue!) shampoo 3 times weekly to help prevent reinfection in the person receiving griseofulvin therapy. Moral of the story: don’t share hats, hairbows, etc.

Plantar warts (verrucae)

Human papillomaviruses cause a number of warts. Athletes are often affected by plantar warts, which are caused by HPV 1 and occur on the plantar surface (or sole) of the foot. Most adult athletes aren’t affected by these because they have already been exposed to the virus as children. Children and adolescents who walk barefoot on locker room floors are commonly affected, swimmers particularly as they often walk to the pool barefoot. There are many treatments for plantar warts, but two-thirds spontaneously regress 2 years after occurrence. Treatments include salicylic acid and liquid nitrogen. Duct tape, a home remedy, has been studied as a treatment, and studies are inconclusive. Treatments may take several weeks to months, and this can be a very annoyingly painful problem for an athlete (or anyone for that matter)! Moral of the story: shower shoes and flip-flops in the locker room and on the way to the pool.

Remember your emollients!

 On deck for the blog:
-winter running (how to fall)
-foot health
-spine health

Ameen M. Epidemiology of superficial fungal infections. Clin Dermatol 2010; 28: 197.
de Haen M, Spigt MG, van Uden CJ, et al. Efficacy of duct tape vs placebo in the treatment of verruca vulgaris (warts) in primary school children. Arch Pediatr Adolesc Med 2006; 160:1121.
Fu T, Keiser E, Linos E, et al. Eczema and sensitization to common allergens in the United States: a multiethnic, population-based study. Pediatr Dermatol 2014; 31:21.

Kakourou T, Uksal U, European Society for Pediatric Dermatology. Guidelines for the management of tinea capitis in children. Pediatr Dermatol 2010; 27:226.

Saturday, January 10, 2015

On Resolutions

I wrote this blog post on New Year's Eve, then got too busy at work to post it, and then got too busy in the following week to remember that I hadn't posted it in the first place, so, at long last... a little something on resolutions.

As 2014 draws to a close and I head in to another 24-hour pediatric inpatient call, I think about how the reflections that occur on this night lead everyone to set lofty goals for the following year. Is it because you party too hard, drink a little too much, and eat too many indulgences on New Year's Eve that you wake up the next day wanting to start fresh in the new year? Whatever the reason, this blog has just a few tips for setting and sticking to those New Year’s resolutions.
Violet helping Mommy do her kettle
bells workout. And you can see our
cat, too. Everyone wants in on my
strength workout! I've got my fitness
buddies to hold me accountable!

1. Set goals that are attainable but make you make quality changes.

My goal for 2015 is to make fitness and health a priority as my daughter gets older and things escalate at work with work + boards studying. My second goal is to strength train at least 3 sessions a week. My third goal is to not beat myself up if I don't exercise every single day because sometimes sleep or getting to see my child for a few minutes is more important. I hate it, but she teaches me balance every day, and she's making me a better person minute by minute! I still haven't decided if there will be another Ironman in 2015 or not yet, but something tells me Violet is going to make me a better Ironman, too!

2. Find people that can keep you going and keep your training smart and healthy. 

If motivation is your problem, then find someone who will either do things with you or who will hold you accountable for your goals. Use a Garmin virtual training partner, train and chart nutrition with friends on apps like Myfitnesspal, find a fitness class or a running, cycling, or swimming group! Start a blog, start an email chain, tell people at work or who you will see every day, post it on Facebook. Make sure people know and will ask you about your progress toward your goal. 

If over-motivation and over-training and injuries tend be your problem, get smart about things (see #3), or find someone who can give you a consistent and safely tailored program that you will follow. Better yet, finally shuck out the cash for a high-quality personal trainer (Shameless plug to contact my husband who is just that!) or a coach for your desired sport to keep you on track. Don't think you have the money? How much did you spend on lattes and ordering take-out last month? You probably do! Give it a try!

3. Don't go from couch to 20-miler in the first week.

Violet doing her baby yoga.

You keep your friendly Sports docs and Orthopedists busy with crazy shenanigans and weekend warrior workouts, BUT, keep in mind that fitness is a life-long journey, and you arent going to lose 20 pounds or train for a marathon or run a 6-minute-mile, or whatever your goal is, all in one day. If you can do your goal in one day, you didn’t set a year resolution; you set a day one! Trying to go nuts in January is only going to make you give up by the end of the month, either out of pure exhaustion or injury, so be practical, make a plan, stay consistent, and listen to your body.

4. Set miniature goals along the way to help you stay on track toward your larger goal.

If your larger goal is to run a marathon in 2015, try some shorter races first, and find a quality program that helps you have adequate tempo and long-slow-distance runs as well as rest and cross-training days. If you haven't been running at all, don't think you can run every day for the same intensity and distance without varying your workouts, taking rest or cross-training days, or strength-training. This kind of thinking leads to overuse injuries such as stress fractures. All components are necessary! Especially the strength training.

5. Athleticism and fitness is more than just cardio!

You need to incorporate flexibility and strengthening exercises into your workout routine, and variety and cross-training also help. You can't just run every day. See #4. 

I wrote this lovely advice for you guys about not going over the top with training, but what did I do the very same day I wrote this post? I ran 5 miles because I was so psyched that I had met my goal from September (when I started knee rehab) to be running again by January. It may have been a bit much for my knee, but my spirit was soaring. But at least I have learned the lesson of making strength training a priority! Baby steps, for this mom with a baby.

So I know where you are coming from, but resist the temptation and play it smart, or injuries may have you not playing at all! Train hard, train often, but train smart. There is no short path to fitness; it is a lifelong and enjoyable journey, which is why I started this blog. Our next series will be on basic physical health topics, and I hope you will enjoy them! Stay tuned for a great 2015, and keep going with those goals!

On deck...
-skincare for athletes
-foot health
-spine health
-finding balance