Hello Readers,

I just returned from the San Antonio Rock ‘n’ Roll Marathon and Half. Some 32,000 participants had a great time and we had a very successful day from a medical standpoint -- though it wasn't without incident. (More on that in a bit.)

You may remember that in a previous post I discussed Dr. Arthur Siegel’s theory about sudden cardiac death (SCD), which is what doctors call cardiac arrest even if it is resuscitated. Dr. Siegel theorizes that muscle breakdown from exertion (rhabdomyolysis) interacts with a plaque (even a small one), which activates platelets to form a small clot that causes enough of an ischemic area in the heart to result in an abnormal cardiac rhythm or arrest. This would not be seen on autopsy.

Dr. Siegel is on to something. In San Antonio, a 32-year-old man finished the half-marathon, then had a cardiac arrest. We successfully resuscitated him and performed cardiac catherization, only to find clean, clear coronary arteries. Because of Arthur’s work, we ordered a serum myoglobin (a marker for the muscle breakdown that Arthur speaks about). Levels were through the roof! This patient appeared to be a living example of Dr. Siegel's theory -- and further evidence of the need to take a preventive baby aspirin (81 mg dose) the morning of a race.

Now, it's true that one case doesn’t prove anything. The International Marathon Medical Directors Association is meeting in March 2010 to develop a multi-city, multi-country research project. It may be that all runners develop high serum myoglobins, since they clear quickly (sometime within one day) -- but they also interact in the body, creating a cascade of other inflammatory elevations that may be markers of risk and may help us to get a better handle on SCD.

As Dr. Siegel says: “Like the runner herein, these SCD victims during races can be saved. But wouldn't it make even more sense to try to prevent the SCD's in the first place? Taking aspirin may just do the trick."

You can help us make this research project "smarter."  If you happen to visit your doctor within 24 hours after finishing a full or half-marathon, please bring a copy of this post with you, record the information below, then e-mail  the results to us at IMMDANYC@aol.com. It will give us greater insight to develop the best research protocol we can.

Please record the following info:

• Your sex and age
• Date and time of last run
• Marathon or half-marathon
• Date and time of blood draw
• Height and weight
• Serum sodium level
• Serum myoglobin
• C-reactive protein level
• CK and tropinin levels
• How much you drank during the run and after the run
• What you drank during and after the run
• Your typical mileage you run per week
• Your typical pace

Anyone who does this will help us enormously.

Meantime, if your doctor says you have no contraindication to taking a baby aspirin the morning of your run, please do it. It may just be the healthiest thing to do.

Enjoy the ride.

Have a question for the Running Doc? E-mail him. NOTE: Due to the volume of mail, we regret that the Doc cannot answer every e-mail.

I experience stiffness in my left knee when I sit for a while. I stretch it out before I run, but it still doesn't go away. This is a problem almost every day. Any suggestions as to what it could be? Why my left leg? I am only 21, so arthritis is unlikely. - Brian

 
Thanks, Brian, for posting this question. Knee stiffness is a very common complaint but unfortunately, over the internet, it is impossible to give you a clear action to the cause.
 
Knee stiffness is a symptom, not a diagnosis. Similarly, if you twist your ankle, causing it to swell up, and  go to a doctor who examines it, x-rays it, then tells you that you have a “swollen ankle,” you wouldn’t be happy. It is a symptom that is caused by something and it is important to find out exactly the cause in order to come up with an appropriate treatment plan.
 

The knee is a closed space. If there's inflammation or a tear within that closed space, fluid builds up, causing it to feel stiff. Usually the weakest part of that space is in the back so it is common for patients to complain that the back of their knee has the pain or stiffness, but the stiffness can be global as well.

 
You will not resolve this until you find a good sports physician near you who can do a history and physical examination; an MRI may or may not be needed depending on what's found on your physical exam.
 
Please let us know what happens after you have a true diagnosis.
 
Enjoy the ride.

 
Attention, Readers!
Are you going to be in San Antonio this weekend? If so, come visit Dr. Lewis Maharam (our Running Doc, a.k.a. "Rock Doc) at the San Antonio Rock ‘n’ Roll Marathon and Half Marathon Heath and Fitness Expo. He will be giving lectures and available at a Medical Information Booth to answer personal questions and sign autographs.

Friday, November 13
1:30 p.m.  Rock Doc's Pre- and Post-Race Medical Tips
4 p.m.  Expert Panel: Frank Shorter, Rock Doc, John “the Penguin” Bingham
 
Saturday, November 14
noon  Expert Panel: Frank Shorter, Rock Doc, John “the Penguin” Bingham
2 p.m.  Rock Doc's Pre- and Post-Race Medical Tips

Location: Alamodome
100 Montana Street
San Antonio

The Health and Fitness Expo is free and open to the public.

* Note: Parking at the Alamodome costs $10 and will apply for the Expo on Friday and Saturday. This fee is issued by the Alamodome. There are alternate lots and parking meters available in downtown San Antonio.

Have a question for the Running Doc? E-mail him. NOTE: Due to the volume of mail, we regret that the Doc cannot answer every e-mail.

Doc, I just finished the New York City Marathon, my first marathon, in 5:40:59! What a great time! I followed all your advice but last night -- starting at about 3 a.m. -- both my feet started killing me. I could not walk! It hurt even to have my comforter rest on them! Is this normal? What is it? How can I prevent it? - Jillian G., Westbury, NY

Congrats, Jillian. How cool to have finished and achieved that goal! And what you write about is not at all uncommon and is actually the greatest complaint call I receive in the middle of the night post first-time marathon finish. As with most injuries and conditions, it is most easily prevented if understood.

What you are describing, if there is no bony tenderness or swelling, is what I call "marathon feet." In basic terms, it is inflamed soft tissues of the feet from the street pounding of the 26.2 (although also seen at the 13.1 distance as well) roads. We most commonly see this in people who have trained on softer surfaces (like the reservoir track in NYC) or who race in thin racing flats when they did not train in them. These inflamed soft tissues get more and more painful until it truly is hard to walk or even put a comforter over them.  

Here are some things you can do to prevent and/or treat "marathon feet":

* Train on the same surface you plan to run on. If you are training for a marathon on roads, the treadmill or a soft track will not prepare your body for the pounding.

* Run in a well-cushioned shoe. Unless you plan on winning the race, racing flats or old, worn-out shoes that have lost their cushion will cause this problem. Remember my “change shoes every 500 miles” rule so that your shoes are not too old or worn.

* After the race, and you are urinating normally (not experiencing “marathon kidney” as I discussed in a previous post on hyponatremia) you may take a non-steroidal anti-inflammatory (e.g., aspirin or ibuprofen) unless your doctor has told you that you cannot due to a contraindication.

* Most important: Immediately upon returning home or to your hotel post-race, soak your feet for 15 minutes in an ice bath. This is the best way to avoid this middle-of-the-night pain.

Now, if you have pain the Monday after the event, 15-minute ice baths three times a day and a non-steroidal anti-inflammatory may be necessary for two days to ease the inflammation. If you feel bony tenderness, see a doctor sooner than later -- what you have may not be "marathon feet" but rather a stress or full fracture of a bone in your foot.

I hope this helps. If anyone out there in reader-land has any other ideas how to prevent "marathon feet," please join the discussion. And Jillian, congrats again. Great job.

Enjoy the ride.

Have a question for the Running Doc? E-mail him. NOTE: Due to the volume of mail, we regret that the Doc cannot answer every e-mail.