the good, the bad, the ugly... & the recovery of a lifetime

Posting this here because though i thought i could write something pivotal and publish in some journal, there are already too many doctor-as-patient pieces out there and i have other projects i need to work on rather than try to edit this and make it beautiful. so, here are my original words without editors and re-writes....

last medal pre-MRSA, May 2019

10.5.2020

A year. A full year since I crutched into hospital where I work, just like I was there for a shift, but instead I was there to say that I thought I needed a work-up and the pain was just too bad. That’s when I start the clock of MRSA septic arthritis, though it had brewed for about 10 days at that point. When I took off my bandage in front of the NP who was seeing me as a patient and not a fellow for the first time, my knee was red and swollen, and pus drained out and pooled onto the floor. Well, THAT looks infected, doesn’t it? It hadn’t looked like that at home, but I had screamed when my daughter barely grazed my leg at breakfast that morning, because the pain was so bad. I had been up several nights in pain, but thought I just had to solider through since I had gone to an Ortho clinic visit that same week and was told it wasn’t infected. In the ED, I waited on my labs, calculated my Kocher Criteria (clinical diagnostic criteria for the likelihood of septic arthritis), and turned to my husband and asked him to go get my laptop from home, so I could do my research project in the hospital because, I told him, “I’m not going home.”

It’s so hard to accept it when you, as a physician, become a patient. The journey of the last year is not one I would repeat. I got a post-op infection from an outpatient knee scope. I hadn’t had a normal knee to begin with, after a congenital bone disease, playing college ball after I had been told I couldn’t play sports at age 13, and then going on to do Ironman races. I had been beating up on that knee for a long time. But it had kept going and just needed a little meniscectomy and loose body removal to get back to regular life, which is for me very active. The cost of it all, of going at such a fast pace and never taking care of myself or slowing down, was MRSA, a resistant bacteria. Maybe MRSA was just the 1 in 1,000 complication of surgery, and I was the lucky one who got to have a real life-check that day and every day for the next year. That, or it turns out you really can’t work like a resident forever, be a mom of 3, and race endurance races without sufficient rehab and strength training. Oh, and sleep. You can’t do it without sleep, at least not for long.

I don’t do anything halfway, and my body and MRSA were no different. It took 3 open knee surgeries with washouts to sufficiently clean out the joint, prior to IV antibiotics for 8 weeks and 2 more weeks of oral antibiotic. My ESR, a laboratory marker of inflammation, stayed high, over 100, for a long time. I had so many adhesions that I needed another surgery, towards the end of my course of IV antibiotics, just to get my knee moving again; I couldn’t bend past 20 degrees. I had spent 2 months in excruciating pain, unable to tolerate even my daughter or husband bumping against the bed or chair my leg was propped on. I could never sleep, waking every hour or two in pain. I also lost the majority of my muscle mass, about 30+ pounds from the nausea and abdominal pain caused by the antibiotics. I couldn’t eat and took multiple other medications to be able to tolerate fluids. I was anemic from surgical blood loss and weak. I fainted a lot, which led to more time not moving around, and more weight loss. The infection and the treatment became one big spiral of loss, not even considering the toll it took on my psyche. The worst of it was that the inside of my knee was so friable, that I actually tore my ACL and had a severe tear of the meniscus that had been frayed prior to the infection. Because I was medical and a fellow in the ED, my Ortho Trauma surgeon showed me video of him ranging my knee in the OR and how the meniscus just flopped off in the joint, back-and-forth, barely attached to anything. He said it was similar to the incision they made to repair tibial plateau fractures. Cool, I thought. Then, man, that sucks.

Maybe that wasn’t the worst. The worst was a tie between being away from my kids for 11 days and being an adult inpatient. As someone who has spent the last 10+ years in the field of pediatrics, I obviously love kids and value the way we pediatricians care for our patients. It’s not that internists and adult surgeons don’t care about their patients. It’s all just different. Maybe more adult wings should have Child Life. Just putting that one out there. I had good nurses and not-so-good nurses. I had techs that I was so very thankful for and truly valued the pride they took in their job, the professionalism with which they helped debilitated folk like myself do demoralizing things like pee and poop on a bed pan or just try to move enough to get sheets changed in the hospital when any movement of your body causes excruciating, mind-numbing pain. I definitely asked for an above knee amputation multiple times, and the Ortho residents were really good about not rolling their eyes at me. I logically thought that it would be great weight-reduction for racing with a blade later, and a good way to end the pain...until I mentioned it to one of my favorite trauma nurses overnight and asked her about amputees and phantom limb pain. She said that they have to treat their pain with opioids, but then they also beat on the stump and say, "I end here, I end here, I end here," over and over again to learn that they don't have their limb anymore. I guess for me that was a moment of remembering all the horrible traumas we see and knowing that I don't end here, even though a lot of our patients do. I followed in the Ortho Trauma clinic, so I saw even more of the repercussions of what we manage in the ED. Eye-opening to say the least.

When someone sees you with your PICC line and crutching on a walker and having to stop to rest, that person with hardware in one leg and one leg missing as well as a splinted hand is sure to give you words of encouragement and tell you their story, too. I went through a lot, but many of our patients go through more with less resources and more obstacles. As a medical professional, I knew how to advocate for myself, but it wasn’t easy. In the hospital, I remember desperately trying to do so but being too groggy on pain meds to think straight. I couldn’t sleep from pain and from being woken up for vital signs and various rounds. I was febrile and septic and nauseated from all the general anesthesia that I got in one week’s time. The day I found out that I had torn my meniscus (I didn’t know about the ACL until much later, and we still aren’t sure when that happened.), I was really down. Non-weight-bearing for 6 weeks sounded like one more hurdle that I didn’t have time for, which is now hilarious, because I was on crutches for months and months due to the infection and the pain. In that moment, however, I was upset that I would have a harder time being a PEM fellow and being a mom of 3 on crutches for 6 weeks. Little did I know the journey I had in front of me. 

I was deflated. I missed my kids. I was crying alone in my hospital room. The floor environmental services (EVS) lady came in as chipper as always to clean my room and saw me tearful. She gave me a pep-talk. My EVS lady! She has no clue how much those words helped me. I still think about it to this day, even though I don’t even remember her exact words, I remember how she lifted me up during a very dark time. You better believe, especially now during the time of COVID, I thank every EVS person I see, every shift. I like to think I would do it anyway, but after what happened to me, and what they do for us and everyone in the hospital now with COVID, I feel a deeper sense of gratitude. They are keeping us all safe, and they do such a thankless job in the hospital. If nothing else from this whole experience, I appreciate my perspective on that. I appreciate how being a patient made me see and feel the way all our medical provider decisions come to light and how important ancillary staff are in caring for patients and helping patients feel actually cared for. I always try to sit down with families and play with my kid patients in the ED or hold babies and talk directly to them. I want them to know I care, but I also just love kids, and that's why I'm a pediatrician. I now realize that those moments of humanity are even more important to families during their difficult times in our hospitals.

There were so many ups and downs on this journey, and they keep coming even now. I definitely had moments of being more positive than my doctors about my condition. At my first ID (infectious disease) follow-up appointment, I told my ID doc that my nights were like having a newborn because I woke up every 1-2 hours, except instead of breastfeeding a crying baby, I was screaming out myself in pain. He was worried about my inflammatory markers because my CRP was 79 at that first visit. I mentioned to him that in the ED it had been 256 and that it was trending down. I said, "Maybe you need to be a more glass-is-half-full kind of guy." That was the good and the bad of it. The ugly was that I still couldn't bend my knee. Even after another surgery to lyse adhesions (scar tissue from so many surgeries and the healing from the infection itself), I still had such a swollen knee even a month out from that surgery. My knee was just angry. Part of me was, too, but with so many obstacles, you really have to look on the bright side and celebrate the small victories, like putting shoes on without wincing in pain, washing your own hair, or being able to walk. My Ortho doc drained 100cc of fluid off at my first post-op visit from surgery #7, the lysis of adhesions, and we both looked at each other, thinking the same thing—he said to me, "At least it's not pus." Maybe that's my mantra for life after this. At least my knee isn't full of pus.  

I have COVID, but at least my knee isn't full of pus. 

Still getting medical bills, but at least my knee isn't full of pus. 

 I'm so behind on life, but at least my knee isn't full of pus. 

 I think I tore my rotator cuff, but at least my knee isn't full of pus.

I look back at pictures over the past year, and the saddest part is how much I feel like I missed of my kids’ lives. Forget that I spent a year not running, a year in pain, months wondering if I would ever walk again, AND that I’m still wondering if I can ever be a triathlete again or can run for my mental and physical health, something that was once so intrinsic to me being me. I missed a gap in my girls’ lives that I won’t get back. I read to them, I watched movies with them, and I tried to sit and watch them play, but none of those things could I do for very long without breaking away to cry in pain. I couldn’t take care of them the way I normally would for months. I was groggy and weak and depressed.

CPM cuddles and my PICC line is finally out.
Things are starting to look up. December 2019.

We all had an emotional journey together. Just as I had to accept my disability and lack of control over the circumstances of my life, and search to maintain my sense of identity and self, they also had to find their mom in the disabled person that I was. My 3-year-old would tell me, “Mommy, soon your leg will get better, and then you will be back to being Mommy again.” Even still, she talks about the activities we will do when I am better. They had regressions and progressions this whole time just like I did. I just had my 8^th knee surgery in June, an osteochondral transplant, ACL reconstruction, and meniscus repair. I told my kids ahead of time what to expect. My baby made me the happiest by actually wanting to cuddle with me this time around. When she was 13 months old last year, she didn’t want anything to do with me because I couldn’t go anywhere with her, and it broke me. This past summer, just shy of 2 years old, she would sit with me while I ranged my knee in the CPM, and her two older sisters would sit as close to me as possible. Somehow, the continuous passive motion machine and my crutches, surgical sleeve, and brace had become our normal. They know what physical therapy is. They know about crutches and walkers. They know that Mommy needs to ice. But none of them remember when Mommy used to go running, and that’s what bothers me the most when I think about the new direction my life might take now.

Post-op surgery #8, June 2020

Over the last few years, I had a goal to do an Ironman as a mom. I ran through most of my pregnancies, and I even pushed Kona in the jogging stroller for runs when pregnant with Juno. As a second-opinion Olympic Team orthopedic surgeon told me when she recommended I give up on my knee and look toward a total knee replacement, “You’ve always been an athlete.” I was only doing short races during fellowship and was just getting back to running after baby 3 when I got my MRSA. I spent so much of the last year in the worst pain of my life, and I am still healing and rehabbing. Now I’ve had time to reflect. Do I really want to prove this to myself, one more Ironman? And would the person I am even stop at one? Do I want to prove that I can do the scheduling and the lack of sleep and the strategic nutrition that training for an Ironman while being a full-time doc and mom to 3 growing girls would take? Do I want to be gone from them for that long? My new orthopedist, one of the top in the country (My knee and I don’t mess around anymore.) seems to think that I could do as much as I want after the 12 to 18 months of rehab that this most recent surgery takes. I’m on month 4, by the way. I am 8 months away from even contemplating the start of an Ironman training schedule.

 

CPM snuggles with my June Bug

Like so many athletes now, though, I am in limbo, and not just due to my injuries and rehab. Who is to say we will have a return to normal sports any time soon with the COVID-19 pandemic? It’s hard to say what returning to my sport would be for many reasons. Maybe my knee couldn’t do the training, maybe the newly diagnosed arthritis in my shoulder would mean I have to give up the zen of swimming and therefore triathlon, too. Maybe I had my heyday in the sun and now it’s time to move on. Perhaps the only racing any of us will be doing is virtual, and then maybe conflicts with kid and work schedules won’t even be an issue anyway. Well, where’s the challenge in that?

If I can be selfish and truly honest for a moment, I just miss the mental high and clarity that comes from running. That sense of inner calm and focus that I have for the whole rest of the day. The last 2 weeks in physical therapy I have been increasing my Alter-G percentage, the amount of body weight and therefore impact on the joints that I do while running. This fancy treadmill that blows up like a balloon holds you suspended in spandex that zip into the bubble, just as weightless as you set the machine. Running at 70% makes me feel like an astronaut in space. Like Flo-Jo flying down the track, or Steve Prefontaine doing "an easy 10", I feel like I could run for hours. Then, last Friday, I ran three one-minute intervals at full weight-bearing on the regular treadmill. I hurt (more than usual) for several days afterward. That was my first run in over a year. After knee surgeries 1, 2, and 5-7, I never really expected to run again. I have made miracles happen on this knee so many times, but I have spent the last year thinking that I need to retire and give up the one thing that makes me me. I know now that I am more than a triathlete, and I know that I can get good workouts from low-resistance exercise, but there’s something in me that still wants to run. I wanted an amputation to run. I just underwent one of the most intense reconstructive surgeries with the longest rehab in the hopes that I might still run, even though it meant putting myself and my family through all those regressions all over again. Somedays I can hear, “You ARE an Ironman,” in my head and actually think about making it to the finish line of another one. And some days, I feel the weight of it all, and all the pain and sacrifices don’t seem worth it. The “anything is possible” slogan might have to refer to the fact that I can be as active as I want with my kids and stay in shape with low-impact exercise, instead of being the athlete I was before. Time to find another sport?

 

 

                                                        Alter-G:  First Run in over a year!

Everything is a process, and I know more about rehab, mental toughness, and chronic pain than I ever wanted to know. Each little milestone meant everything to me and was celebrated in some small way~ bending my knee past 20 degrees, lifting my leg for a straight-leg raise without tears, getting my PICC line out, crutching all the way upstairs for the first time, washing my own hair, putting on pants without sitting down, and now bigger ones like going down stairs faster than Juno! (I can finally alternate feet going downstairs and she is still doing one leg down and both together, like I basically did for the last year until recently.) I had to learn to walk again, which was literally the hardest step of this journey. Now I have to learn to run. My physical therapist mentions that the next step is cutting and jumping, something I gave up on a long time ago when I chose to be a triathlete as my next athletic career after college basketball. I thought I had done my major athletic journey back when I did 6 weeks of non-weightbearing in college and 5 months of intense rehab to finish out my career and play my senior year, following a meniscus repair and loose body removal surgery. I did another year of rehab after college before endurance racing and triathlon seemed possible. How simple and easy that all seems now! I tell my PT at Ironman TMC now that I don’t care if I can ever jump or cut again; I just want to run. But, maybe I do need to jump and cut, though. Violet’s favorite sports now are tennis and basketball. You better believe I’m going to be out there on the court with her when all is said and done.

 

La Vie en Rose: Lessons in Endurance Training_4.17.19

Holy smokes, folks! Has it really been almost 3 years since I last blogged on here? A few things have changed- Violet will be turning 5 in a few weeks, and she has 2 younger sisters! I am wondering why I haven't written in so long, but then I look down at the fact that I am writing this with the Haaka on one side and Juno on the other, in a post-run post-breastfeeding high, thinking I only have another hour on this day off before it is time to start dinner and pick up the hooligans (our loving name for our older children that keep us laughing and grounded and crazy all at the same time), and I realize that reflection and also research on health topics haven't necessarily been high on the priority list lately.  I started a career in PEM (Pediatric Emergency Medicine), moved to Texas, started fellowship, and we added to our already growing family here. Now with 3 kids + fellowship, a 3-year blog hiatus sounds small. 

Juno is here! 8/2018

BUT, as I am back to semi-endurance training again, almost 8 months post-partum from 3rd kiddo and 2 weeks out from the Indy Half-Marathon, it occurred to me that I had some things to say that were too long for one of my rambling Facebook or Instagram posts, so a blog seemed like a good idea. During my 5-mile pace run today, I was realizing that though there have definitely been some lulls in training for high-risk pregnancies or post-partum knee rehab, I have actually been an endurance athlete for 10 years now! I was thinking today about how mind-clearing running is for me and how it really is an act of personal kindness and intellectual wellness. Today while I found my stride for the first time since starting to train for this race 2 months ago, these are the tips I was thinking about that I have learned during the crazy journey that has been my re-return to fitness over and over again over the last 10 years.

Family trip with rose-colored glasses

1. la vie en rose
Seeing the world through rose colored glasses. The title of this blog comes from a moment the other day with my girls when Violet was trying on my sunglasses inside (while we were trying to eat breakfast and get off to school nonetheless), and she told me, "Mommy, do you know when you look at the light through these, it's pink?" She was right. My cheap drug store sunglasses that are now all scratched from being around these kiddos do have a pink tint to them that I had never noticed before. I played the song "La Vie en Rose" for them and we pretended we were eating at a French cafe, and we talked about seeing things in a positive light. There is nothing more important in endurance training or in life than staying positive. I am honestly so bad at this, but I am working on it. There are so many setbacks and obstacles in training, and you will help yourself out by not letting yourself get bogged down by one bad mile, one bad run, one off week, etc. My Numa sports glasses that I have actually been wearing for racing for the past 10 years are rose tinted sunglasses. How funny that just now I am seeing the symbolism in that and hoping it will keep me positive and not allow myself to be my toughest critic.

2. Don't expect perfection
This lead me to my next lesson- don't expect perfection. Not out of yourself but also not out of your training. As someone who has had Ironman races cancelled for hurricanes and done marathon training in thunderstorms, racing and training is never perfect. Don't plan your training schedule or your life too much. Go with the flow

Running at 30 weeks pregnant pushing my Kona Bean in 103 F Houston heat

3. Don't be embarrassed by your pace
Everyone is running a different race, has different obstacles, has different goals. You don't need to compare yourself or push yourself beyond reason. I am the worst at this. I want to be a better version of me- the doctor me, the mom me, the wife me, and the athlete me. Dude, something's gotta give. I finally accepted that I am going to run this race at a pace that is embarrassing to me, but I also could very easily be not training at all or waiting for the right time to jump back in, and honestly folks, with that mentality, it may never come. Maybe I'm never going to have an endurance pace of 9-minute-miles (I used to lust after 8 or 7-minute-milers.), but I'm out there getting my runner's high, and that in and of itself is really enough right now. Because I finally accepted my pathetic pace, I had a really strong pace run today because I wasn't chasing a pace the whole time that was too much for me. Getting faster is something I will do after this race. It's okay to set these kind of goals for ourselves, especially when you haven't been racing. You aren't going to be able to do endurance and speed training in your program unless you're already up to snuff. This is my first time running postpartum without knee rehab first. Mistake? Not yet anyway. :-\

Juno likes my Camelbak! Post-run, sweaty cuddles

4. Treat your allergies and wash your hair after workouts! - 
Flonase. It's class C in pregnancy, which I guess is why I haven't used it in so long, but my life is forever changed from starting this medicine again 3 weeks ago. Turns out not blowing snot rockets your entire run is very uplifting. Bad allergies? Take Zyrtec, Singulair, and Flonase. Works great for asthma, too, since Zyrtec and Singulair work synergistically in allergic asthma, and flonase has been shown to improve asthma as well.
Wash your hair. This is so time consuming and annoying, especially busy parents and others who find themselves barely having time to fit in the run much less the shower, but washing the allergens off after running including getting them out of your hair and nose (Neti pot or Sinus rinse anyone?) is key to ensuring that you don't sleep in a carpet of pollen on your pillow that will keep you stuffy all night and into the next day. Curly hair? Use a cleansing conditioner so you don't dry out your hair! I love Amika :) 

Stay tuned. I imagine this blog will evolve since I'm PEM now, but we'll come up with some good topics or just random life updates on whatever race or obstacle is next! :-P

Tips for Spring Training

I know I owe everyone some really good blog articles on fun sports and medical topics, BUT I realized that I haven't found the time to write something for you since January, so this means a quick blog to get us started and then hopefully some more research-based things coming up soon. All of my research writing time has gone into actual research and not blogs lately, go figure!

Tips for Spring Training -

1. Embrace the Awesome

having a blurry fun time and ready
for spring swimming!!!!

This spring weather makes everyone go park and exercise crazy. One of my new favorite catch phrases is #embracetheawesome. (I thought I made it up and was so excited, but when I wrote the hashtag, I realized a bunch of other people have already used it. Oh well.) At any rate, still Embrace The Awesome. This spring and sunny weather has you gliding on air and ready to spend every last bit of daylight out enjoying the essence of spring...then go with it! Use that boost to get yourself back to being active again, pump up your bike tires, dust of your running shoes, grab your tennis racket, make it happen!

2. Stay hydrated
This goes without saying, but you may forget how much hydration you need to bring with you for workouts or how to replenish afterward. With warmer weather, there is more sweating, more salt loss, and hydration and rehydration become even more important. A good rule of thumb is that your pee should be clear prior to your workout (concentrated urine that looks darker is a sign of dehydraton). More than an hour of strenuous exercise in the heat means an electrolyte replacement drink after, and  you should have a protein and carbohydrate meal/snack within 30 minutes of endurance training if possible, to maintain muscle mass and properly replenish glycogen stores.

3. Don't Forget the Sunscreen
Athletes are the biggest culprits of not using sunscreen. You think you have a base tan, you think you want a base tan, you think you don't burn easily...well you're all wrong!
Watch this enlightening video with an ultraviolet camera, showing how sun exposure affects your skin.

Dandelions on the soccer field? Those are ok...right, Violet?

5. Check field conditions
This should be up to the schools and the coach for youth sports, but sometimes things are getting revamped when they need to be. Make sure things are up to snuff before your kid heads out on the playing field. Adults, you should know better when you are playing sports later in life.



     6. Check equipment

Wondering where her sun hat is while playing ball.

   If you are like me, you haven't pumped your bike tires since you last did an outdoor ride or oiled your glove since last fall or summer.
I am so bad about leaving my bike on the trainer and letting the front tire go totally flat, and then as soon as the weather turns nice, I get frustrated when it takes me an hour to get everything ready to go for an outdoor ride. BUT, it is definitely worth it to pump the tires, check air pressure, make sure your flat kit has everything you need, and that everything is functioning properly since your last time out. This goes for every sport, especially for kids. Make sure they have the right equipment to help prevent injuries.


7. Consider body type and any changes

That bike is too big for you, Violet!

This is especially important for youth sports, but it applies to adults as well. Adults may not be in the same shape they were the last time they decided to play a certain sport or enter a certain level of training. Even elite athletes need to recognize physiologic changes and hormonal differences since the last season or big event. For ladies even menstrual cycle can affect training, as well as adaptation after pregnancy or miscarriage, premenopausal changes, etc. For men, different amounts of muscle mass or endurance training can affect testosterone level and athletic performance. So please talk to your health professional or your experienced trainer or coach about these when setting your goals and training regimens. For kids, especially around the time of puberty, parents and pediatricians need to consider the stage of puberty and the growth velocity that has occurred over the last year. I will write another blog specifically on this topic, but being at a younger bone age or a younger stage of puberty compared to other kids in the same grade can put a child at a disadvantage not just for athletic performance but for athletic injuries. This is most important for contact sports. Talk to your doctor and make sure a check-up happens to see where your child is with regard to Tanner Stage (or SMR Sexual Maturity Rating). Yes, that means putting on a gown and getting your private parts checked. All pediatricians should be doing it with the annual health maintenance exam. Parents please ask if they are not.

8. Know your stuff!
This is supposedly going to be a great website for parents especially to check what sports need what prep prior to gearing up for spring training or any season, for that matter. However, right now it is still under construction. Check back later and see what info they add: stopsportsinjuries.com.

9. Try something new
A great way to cross-train is to keep yourself doing some different sports at different times of year. Yes, we all have that sport that we love the most, but getting better sometimes means a little time of from it, and this gives you time to enjoy something else! This is also a good way to avoid over-use-injuries. We should probably have a couple blogs on those coming up.

10. Be inspired

I was running recently and saw two women running with reflective jackets. One read “Guide” and the other “Blind-Deaf.” So these two ladies deserve a super shout-out because they were moving fast! Total inspiration. I spent some time on my run wondering what it would be like to run a race and not be able to hear any of the fans cheer. It makes you think you are pretty fortunate to have what you have, and it also makes you applaud these ladies for getting out and running and exercising their ability to stay fit, despite life’s obstacles. Great job! You better bet I will be thinking of them in some of my upcoming races, trying that much harder because I can hear and see people cheering for me and know how special that gift is.

We love animals and we love running! Help us support
the Bronx Zoo!!!!!!! :-D

I find that sometimes signing up for even a small race is a good way to enjoy the nice weather and get yourself exercising when you otherwise wouldn’t. Our family signs up for the Indianapolis Mini Marathon every year, and I definitely wouldn’t have been running much recently without having this race on my calendar. I have been taking a training break, which means running a half-marathon only this year lol. Violet and I also decided to do her first race at the end of this month- a run for the Bronx Zoo. I think it’s a win-win. We get to go to the zoo, Violet gets a ride in the Enterprise (our jogging stroller), I get exercise, and the zoo gets some financial support from the fundraising. If you are local and interested in joining us for the run, check out this link. If interested in donating, go here.

References:
Von Duvillard et al. Fluids and hydration in prolonged endurance performance. Nutrition. 2004 Jul-Aug;20(7-8):651-6.


On deck:
-Back Pain (I am not forgetting you, Charles! we Will try to do this one next)
-Overuse Injuries
-Neurodevelopment and Youth Sports Training
-Ankle exam and injuries for providers
-Knee exam and injuries for providers

Intoeing Part II: The Pluses and Minuses of Pigeon-toed Anatomy in Athletes

Last blog we went over the different causes of intoeing in kids. Now we review what intoeing means for athletes.

Studies have shown that low to normal thigh-foot angles and intoeing while sprinting correlate with sprinting ability. Meaning, if your anatomy is such that your thigh-foot angle is low and makes you prone to intoeing and you continue to intoe while you sprint, you may be a better sprinter than those who don’t! Or, you may just be overcoming your anatomy and sprinting well despite your intoeing. It is hard to say which the case is. Have observational studies shown more sprinters who do well because they are pigeon-toed, or do sprinters just happen to have some pigeon-toers who sprint well? Usain Bolt has been noted not to intoe while sprinting. Andre Agassi and Michael Jordan, two athletes who have excelled in sports that require lateral movement (i.e. tennis and basketball) are pigeon-toed. Biomechanically speaking, lateral movement is easier when done with toes turned inward. Is this the case with sprinting?

Violet can't figure out if her rain/snow
boots make her intoe more or not.
She runs pretty fast in them!

The theory to explain the mechanism based on biomechanics and physics from the leading exercise physiologists goes something like this – runners land on the outside of the foot and roll their foot inward from heel-strike to toe-off. People with intoeing have less of this maneuver because they already land partially rotated due to their anatomy. They have less give in the foot and ankle joint when they strike, and the stiffer foot means less energy is absorbed and more energy is dissipated. Running speed is increased when an athlete’s body has the capacity to handle the impact of the forces that occur when the foot strikes the ground, forces that are 3 to 6 times bodyweight. A stiffer foot enables the athlete to absorb these forces and quickly accelerate in the opposite direction.

Some folks propose that intoeing, associated with having flat feet (pes planus) and bow legs, may lead to being faster, but it also leads to more ankle, knee, and hip injuries. The theory being that intoeing feet don’t cushion the force, so even though they are faster, the musculoskeletal system incurs the consequences of that impact. A recent literature review actually showed that there is a low association between pes planus and lower extremity musculoskeletal injury. I haven’t found anything that directly reviewed intoeing with lower extremity injuries, but since the theory is based on the association between intoeing and pes planus, I think we can safely say that there is low evidence to support it. So, dream on, athletes, for those pigeon-toes.

Violet checking out a runner's gait
and trying to decide if they are
hyperpronating or not. There's a lot
less entertainment during winter jogging
stroller runs because fewer people and
fewer animals are out. Why aren't they
as crazy as us, sweet girl?

References

Budt et al. The relationship between foot posture and lower limb kinematics during walking: A systematic review. Gait Posture. 2013 Jul;38(3):363-72.

Feigenbaum et al. The association of foot arch posture and prior history of shoulder or elbow surgery in elite-level baseball pitchers. J Orthop Sports Phys Ther. 2013 Nov;43(11):814-20.

Fuchs R and Staheli L. Sprinting and Intoeing. Journal of Pediatric Orthopaedics. July/Aug 1996: 16;4 – 489-491.

Tong et al. Association between foot tye and lower extremity injuries: systematic literature review with meta-analysis. J Orthop Sports Phys Ther. 2013 )ct;43(10):700-14.

Zafiropoulos et al. Flat food and femoral anteversion in children—a prospective study. Foot (Edinb). 2009 Mar;19(1):50-4.

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.

References:

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. 

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!)

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.

 Fitbit

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!

Nike FuelBand

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.

Jawbone

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.

Garmin

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!


References:
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!