SPECIAL BOOK BONUS

The Role of the Podiatrist in the Overall Health of the Runner Cannot Be Overstressed.

Parts 1,2, 3, and 4 of Dr. Sheehan’s book appeared in our last four issues.

Ten FEET AND LEGS

Iam a cardiologist, but my relationship to sports medicine has been as an athlete rather than a doctor. What I have experienced as a runner—and what judgment Ihave been able to bring to this experience as a physician—have convinced me that traditional medicine isn’t dealing adequately with athlete problems.

In more than 10 years as a distance runner, I have experienced almost every injury of the foot, leg, knee, thigh and back. During that time, the medical profession has only been able to provide me with symptomatic relief. It wasn’t until I came under the care of a podiatrist (foot specialist) that I was able to run for prolonged periods and be free of foot, leg and knee difficulties.

Yet the medical profession has been slow in adopting this method of treatment which obviously is effective. The standard treatment of the most common ailment of runners, chondromalacia of the knee (which I call “runner’s knee” because the technical term is so clumsy), is a case in point. Runner-patients are still advised to rest, wear casts, try a variety of medications, do quadriceps exercises and, when all else fails, to undergo surgery.

In my first years as medical columnist for Runner’s World, I made these same suggestions to the victims of runner’s knee. There must, you see, be a standard operating procedure—even if it doesn’t work.

Meanwhile, I was getting hints that the foot was the cause of it all. A high school runner told me that he had trouble with his knee if he wore a certain pair of shoes. Another runner had pain while using a banked track. I had knee pain and found it was due to the slant of the road. My left knee gave me trouble if I ran with traffic. I cured the pain by running against traffic, and thought no more of it.

No more, that is, until I began a lengthy correspondence with Tom Bache, an ex-Marine and a fine runner in the San Diego area. Tom had suffered from runner’s knee for two years when we began to exchange ideas. He had gone through every

therapy suggested in the literature (short of surgery), without success. As soon as he got back to running, the pain returned.

I wrote to Tom about the crown-of-the-road idea and about running on the outside of the foot. This helped him until he would forget, get tired or lose form in arace. So this problem continued. Neither Tom nor I thought of the next logical step, foot supports, until his arch started to bother him and he sought help from runner-podiatrist Dr. John Pagliano.

Dr. Pagliano fitted Bache for supports, and viola! Tom lost his knee pain and in a matter of weeks was up to marathon training. He ran the best marathon of his career shortly after.

After this experience, I saw the number one man on a local college crosscountry team. He had severe symptoms of runner’s knee. I looked at his feet, and even to a cardiologist his problems seemed evident. His feet were a disaster area. After podiatric treatment, he returned to running again within a week and was completely asymptomatic.

Soon I was seeing tennis players with the same problem, and hearing about more and more runners who were being helped with drug store supports, and others who had reached to podiatrists for treatment and were back to full-scale running. The treatment was successful not only for knee pain but for the gamut of injuries along the foot-leg chain.

This convinced me that no matter what an athlete’s complaint is, we should look first to his feet as the source of the trouble. The foot is an architectural marvel—an engineering masterpiece which has 26 bones, four times as many ligaments, and an intricate network of tendons which act as guide-ropes or slings for the arches. When these components are perfectly balanced, the foot can handle almost any amount of work. However, even a minute deviation from normal can cause adjustments that will eventually produce injury either in the foot, or in its supporting muscles and tendons, or even in the structures above it.

When this happens, we have familiar afflictions such as heel spurs, achilles tendinitis, shin splints, calf pulls, stress fractures and the ubiquitous runner’s knee. In sports medicine, these problems are lumped under the category of “overuse syndromes.” It was originally felt that excess activity was the sole cause of the trouble, and remedies were directed to relieving discomfort, to allowing a suitable period of rest and then to resuming the training activity.

Unfortunately, the presence of an “X” factor was not suspected and therefore was left uncorrected. Hence, the result of therapy was predictable. The athlete went through a sequence of pain, followed by relief through rest and treatment, and a return of pain when training resumed.

The long-suffering athletes cried, “Why me? Why a good guy like me? Why should I have trouble with my feet (or knees or legs) when my teammates who practice as much as I do have no difficulty?”

The answer is that the ailing athlete has an inherent susceptibility to his injury. And this susceptibility, the “X” factor which the medical profession is so slow to recognize, was a structurally weak foot.

When an athlete goes into training, three things can happen to his muscles. Two of them are bad: shortening of the strengthened muscles with loss of flexibility; weakness of the opposing, relatively unused muscles.

“The irony is that the athlete is less fit in regard to flexibility standards than the typical man in the street,” writes Fitness for Living editor Robert Bahr. “That’s because strengthening and endurance exercises act to shorten muscles and reduce flexibility.” It is Bahr’s belief also that more muscle tears, pulls and strains occur because of this lack of flexibility.

The best answer to this lack of flexibility is yoga. For one thing, in yoga the stretching is gentle, smooth, non-painful and

achieved over a period of time. “Stretching by bobbing and bouncing,” writes physiologist Dr. Herbert de Vries, “invokes the stretch reflex which actually opposes the desired stretching.”

Yoga or not, the stretching athlete is only halfway home. He has to start strengthening exercises of the weakened antagonist muscles. This will prevent the imbalance in muscle strength that many observers feel is the other major cause of

pulls, tears and strains. “A number of studies have shown,” says physiotherapist Joseph Zohar, “that when one muscle group is excessively stronger than the opposing muscle group, the odds of injury in the weaker muscle are greatly increased.” The evidence is

that an excessiveAN Mayne ly high ratio of Michael Hughes strength between

the quadriceps (the front thigh muscles) and the hamstrings (the rear thigh muscles) increases the chance of a hamstring pull.

The principle is easy, the application difficult. Each sport strengthens and therefore shortens a different set of muscles. The flexibility problems of a sprinter, for instance, differ from those of the distance runner, as do his muscle imbalances. The distance runner has stronger, shorter hamstrings and therefore tends to pull

is weaker quadriceps. The sprinter who uses his quads to explode out of the blocks has weaker hamstrings, and the back of his thigh is where he grabs when e gets that tearing sensation midway in the 100-yard dash.

The main interest of the people in sports medicine is not to predict these events (which some researchers have done by testing athletes) but to prevent them. The biomechanical approach to muscle balance provides just such a program. It is part yoga, part muscle balancing. Zohar calls it preventive conditioning. What it means is that no weakness, no tightness, no muscle imbalance will go uncorrected.

When an athlete trains that way, when he applies engineering and architectural principles to his body, he doesn’t have to worry about the two bad things that usually happen. And he may even get some unexpected dividends.

“The balanced conditioning of individual muscle groups,” states Zohar, “not only protects the body against injury but also improves its performance to unprecedented levels.”

The human body is a marvelous instrument. When in perfect alignment and

balance, there is almost no feat of endurance the body cannot handle even on a regular basis. However, structural imbalance of even minor degrees can result in incapacitating injuries and persistent disability. Prevention and treatment of musculoskeletal problems in the athlete, therefore, rests on the establishment of the structural balance and architectural integrity of the body—and its re-establishment should injury occur.

There is very little place in the treatment of these diseases for injections, medications and manipulations. Treatment rests almost completely on the following:

Biomechanical treatment of the foot. This means providing a foot support or orthotic, which keeps the foot in proper balance. Ordinarily, this entails the preservation of the neutral position of the foot. What we do is bring the ground up to meet the foot, thus preventing it from flattening or coming over on the inside (pronating).

Flexibility and strengthening of the muscles. Ordinary training involves the continual repetition of one motion and the use of one main axis of muscles. This results in two unwanted effects: (a) shortening and loss of flexibility in the exercised muscle, the prime mover, and (b) weakness in the antagonist which opposes it. Additional exercises are needed to prevent this.

It would be wrong to consider these measures as “either/or.” Both are necessary. Biomechanical problems in the foot are accentuated as the muscles tighten and their opposing muscles weaken. Treatment to the muscles, therefore, lessens the required corrections of the feet. Conversely, using orthotics for the shoes can lessen the symptoms due to muscle imbalance in the leg, thigh and back. This is particularly true in instances of the “‘short-leg syndrome,” now thought to be due to muscle spasm and to be helped by both heel lifts and muscle reeducation.

Using these general principles, one can move on toa general preventive program. First, the runner must review his feet with three major abnormalities in mind:

Morton’s Foot: This is a short first toe with a long second toe. The short first metatarsal tends to pronate the foot and cause failure of the long arch as well. This (and other pronatory influences) can cause such problems as:

1. Heel spur syndrome. This is improperly called a heel spur. Actually, it is a fasciitis, an inflammation of the plantar fascia which attaches to the heel spur and spreads across the foot like a fan reaching to the toes.

2. Posterior tibial tendinitis. This causes pain on the inside of the leg along the shin bone. Sometimes it is mistakenly called shin splints, a term reserved for pain along the front of the leg between the two shin bones.

3. Chondromalacia or “Runner’s Knee.” This causes the pain and occasional tenderness under the kneecap and sometimes to either side. It results from the foot flattening out and transmitting a torque to the knee, causing the kneecap to ride over on the knob of the thigh bone.

Loss of the long arch. This can cause all of the above.

Unstable heel. This movement can result in achilles tendinitis and “runner’s knee.”

Prevention for these conditions would include a heel cup, minimal heel lift, a longitudinal arch and a Morton’s extension. Judicious use of arch “cookies,” heel cups and felt for heel lifts, arch supports and Morton’s extensions can be done on a do-it-yourself basis.

Next, the runner should review his muscular status. The distance runner will shortly find that he has established tightness of the muscles running from his foot to his low back. The achilles will tighten, as will his gastrocnemius, hamstrings and iliopsoas. Meanwhile, his front muscles, the anti-gravity muscles, will become weaker. When this happens, he is in trouble. The difficulties to look for are as follows:

Inflexibility of the achilles. This leads to achilles tendinitis and worsens any biomechanical problem in the foot. It also overbalances the shin muscles and makes them unable to handle stress.

Tightening of the hamstrings. This contributes to low back and sciatic problems. It also sets the runner up for a quadriceps pull through relative weakness of that group. It contributes to the short leg syndrome.

Weakness of any of the opposing muscles, including the anterior chamber muscles (shin splints), quadriceps (quadriceps pull) and stomach muscles (rectus pull), sciatica and low back problems.

Preventive maintenance therefore involves the following: (1) foot care, (2) flexibility exercises, (3) strengthening exercises.

When faced with an injury not due to a collision or a fall, the runner must assume that he is out of structural balance. No medication is going to restore that balance. He must get down to basics, diagnose where he is out of line and correct it. He will get temporary relief with whatever the doctor recommends, i.e., rest, butazolidine, cortisone shots or whatever. But as soon as he resumes running, he will quickly get into trouble again.

With this in mind and remembering what we have said about structural balance, let us consider some of the most frequent running ailments and proposed treatment:

° Achilles tendinitis: Cause—short achilles, gastroc hamstring axis; unstable heel; inverted heel; weak arch, excessive use of toe flexors. Treatment—stretching of achilles; heel lifts, arch supports; anterior crests.

° Heel spur syndrome: Cause—no shank in shoes; Morton’s foot; weak foot; forefoot varus. Treatment—‘‘doughnut” for heel; full foot orthotic for forefoot problems as well as arch; shoe with good shank (Tiger Corsair, Nike Cortez, Puma 9190, Adidas Country or SL-72).

° Stress fracture, metatarsal: Cause—unstable heel; weak arch; other pronatory abnormalities and forefoot problems. Treatment—full foot orthotic with attention to Morton’s foot; forefoot varus and unstable heel.

° Runner’s knee: Cause—pronatory foot influences including the unstable heel, weak foot; forefoot varus and Morton’s foot. Treatment—heel stabilizer; arch; possible full foot orthotic.

° Numbness of the feet (distance runner’s neuropathy): Cause—sciatic nerve pressure. Treatment—stretching of hamstrings and iliopsoas along with abdominal situp (bent leg) and isometric tummy tucking.

* Other sciatic syndromes, pain in the thigh and buttock: Cause—tight hamstrings, iliopsoas, weak abdominals. Treatment—use same flexibility and strengthening exercise; use of Sacrogard belt (usually $6-8 at drugstores).

* Shin splints: Cause—weakness of the anterior chamber muscles. Treatment—strengthen muscles by flexing foot with weight over toes; anterior

crest to lessen use of flexors stretching for the opposing muscles, the achilles and gastroc and hamstrings.

* Groin pain: Cause—unknown but probably a mixture of weakness of the adductor muscles, the short leg syndrome and biomechanical difficulties in the foot. Treatment—advise flexibility exercises along with exercises drawing leg toward the mid-line; attention to any biomechanic problem of the foot, however mild.

We are dealing in problems measured in millimeters. Often the injury is precipitated by wear of the regular training shoe down to a critical point—the heel, for instance, where an eighth of an inch makes the difference. Use of a totally new type of shoe for a major effort will also bring on difficulties, as will change of surfaces and even change of direction when there is a slant in the road.

I cannot emphasize too strongly that this is a structural, almost architectural, problem, not a medical one. You would almost be better off in the hands of an engineer than a doctor when these illnesses strike. At least you would not have your problem complicated by medication which in the long run will do no good. What the runner needs is to be restored to structural balance. Acupuncture, surgery or wonder drug will not do that.

Eleven HEART AND MIND

Is there an athletic heart?

Yes, there is. Athletes have bigger and better hearts than the ordinary person. We have always sensed this. Our heroes have been called mighty-hearted and greathearted and lion-hearted. The word courage takes its root from the Latin word for heart. Now scientists using echosound to map out the exact dimensions of the heart have been able to prove the athletic heart exists.

How does an athletic heart differ from an average heart?

The studies at the National Heart Institute in Bethesda demonstrated two basic types of athletic hearts: “endurance hearts,” found in swimmers and long distance runners, are bigger, “resistance hearts,” seen in wrestlers and shot putters, are heavier.

What are the characteristics of the endurance heart? The emphasis in this heart is on the filling phase or diastole. Endurance training demands a high cardiac output for long periods of time. The heart adapts by increased filling.

In such athletes, the volume at rest may be twice that of the ordinary citizen. Nevertheless, the heart wall does not thicken, but the entire heart grows larger.

The largest hearts on x-ray study are those of professional bicyclists, closely followed by marathoners and cross-country skiers.

What are the characteristics of the resistance heart?

Here, it is not the volume of ejection that is important, but the force. Training in these sports is for sudden, severe maximal effort. The time element is relatively brief. As a consequence, the wall thickens while the capacity of the heart changes very little. For this reason, enlargement is not too evident. Hearts of shot putters, gymnasts, weight lifters and normal controls look much the same.

The echo, however, shows the truth of what Harvey wrote in 1628: “The more muscular and powerful the men, the stronger, thicker and denser their hearts.” These are hearts that emphasize systole or contraction, while the runner’s heart depends on diastole or expansion.

Is the athlete heart normal?

If fitness is normal, the athletic heart is normal. If the ability to work with vigor and pleasure and without undue fatigue is desirable, then the athletic heart is desirable. If we were created to live at the top of our powers, then the athletic heart is necessary for the good life.

Is there any danger with an athletic heart?

The main danger is going to the doctor. Physicians are generally unfamiliar with exercise physiology. They become alarmed at the normal physiological changes that accompany heavy training and peak condition. They are, therefore, likely to give bad advice that could cause an athlete to quit his sport, lose his livelihood and be ineligible for life insurance.

What are these normal “abnormal” findings in a trained athlete?

These occur mostly but not exclusively in endurance hearts: (1) slow pulse—rates can go down as far as 28 beats per minute; (2) irregular pulse—premature beats and heart block; (3) low blood pressure; (4) orthostatic hypotension—the blood pressure goes even lower when the athlete stands up; (5) heart murmurs due to the force and volume of flow; (6) third heart sounds, which under other circumstances suggest a weak heart; (7) abnormal EKGs—the Wilt Chamberlain Syndrome where the heart tracings are almost identical to those seen in heart disease; (8) elevated blood enzymes—usually seen in heart and liver disease, here the increase is due to muscle breakdown in training; (9) enlarged heart on x-ray.

If all these abnormalities are normal, what about sudden death in athletes? Wherever adequate investigation has been done, sudden death in athletes has been found to be due to some underlying disease not caused by the sport. The only lifethreatening danger to healthy athletes is heat stroke. Severe prolonged exertion in hot, humid weather can kill the unacclimated dehydrated athlete.

1s the athlete at hazard if he gives up his sport?

Theoretically, the ex-athlete simply detrains. After a period of time, he joins his non-playing friends in their state of fitness, or cardiac thrust and cardiac output. In actuality, the athlete who stops his sport tends to continue eating at the same rate and therefore gains an excessive amount of weight. Some cardiologists speculate that this results in a fatty heart.

A philosopher might take an even more pessimistic view. There is no greater privilege than the wholeness of the completely trained and conditioned athlete. The abuse of that privilege must have profound effects not only on his heart but on his mind and soul as well.

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Some 30 years ago, I collapsed after a flu shot and an electrocardiogram was done. It was read as abnormal. There were odd-looking T-waves and a blockage of the electrical conduction through the heart. The cardiologist who knew me as a former distance runner did not get excited. He suggested, however, that I best conceal it when I came up for my Navy physical, or I would sit out the war. His colleagues, he intimated, would not be so understanding.

Some 10 years later, I made the mistake of mentioning the EKG during an insurance exam. More EKGs were done. The weird electrical events had, if anything, gotten weirder. They also tended to change from one test to another, which alarmed the insurance people even more. The upshot was that I was offered a policy with the proviso that I pay a double premium.

When I called a medical examiner with a rival company and told him a friend of mine was paying this double premium because of his odd EKG, the examiner assured me his competitors were quite right in imposing the penalty. “Those people,” he said, “tend to drop dead.”

Yet at that time I was racing miles and marathons and running 30-40 miles a week. I’d never felt better in my life. Which is why now I advise every athlete to regard the electrocardiograph machine as a deadly weapon in the hands of those who do not know that fitness and training and inheritance can produce a normal “abnormal” reading.

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If the aim of the medical profession is to stop the average American from exercising, it couldn’t have done a better job. It is not enough that weather and work and family conspire to make physical fitness as difficult a goal as the peak of Everest. Now the doctors are insisting that before you embark on such an expedition you should not only have a complete physical but an exercise stress test as well.

You know, of course, that a complete physical is not going to turn up anything that your spouse has not already itemized—the stomach, your hips, the double chin. And you know that the recommendations on smoking, drinking and eating

will be no different from those already suggested by your mother-in-law. You already know the doctor’s verdict: “Good health; lousy shape.” So you could talk yourself out of the physical.

But what about the stress test with EKGs and all those sophisticated instruments? Isn’t that a logical requirement?

You should know that some experts think the exercise stress test is a highly restrictive and expensive and probably unnecessary precaution (Dr. Gordon Cumming, Canadian cardiologist). And others judge it to be of no great value even in the diagnosis of coronary disease (Dr. Stephen Epstein, National Heart Institute). Further, when given without a warmup to presumably healthy people, 70% abnormal results were obtained (Dr. Albert Kattus, UCLA). And in apparently normal women, ages 40-60, almost half had abnormal stress tests (Dr. Cumming). If this isn’t enough to raise doubts, we should note that European physiologists suggest that much of what we call abnormal is simply excess nervous tone.

Still, as the doctors contend, we do need something to help us prescribe the intensity, frequency and duration of our exercise periods. Fortunately, that something is built into every one of us. Its discoverer, Swedish professor Gunnar Borg, calls it “perceived exertion.” Whatever its name, perceived exertion is the ability to digest all the information coming from the exercising body, the muscles, nerves, heart, lungs, kidneys and everything else, and translate that information into an estimate of physical exertion. What we are doing physiologically, Borg claims, registers quite accurately on a psychological index (rating of perceived exertion).

What this means is we don’t need all this electronic wizardry to tell us how hard and how long and how often to exercise. We simply set our Borg scale at “very light” to “fairly light” and start in. If we keep within those bounds, move at a pace at which we can converse with a companion, go at a speed that causes neither chest pain nor excessive fatigue, we are better off than with a treadmilltested prescription.

Don’t forget that laboratory tests are just that: performed at 70 degrees temperature and 40% humidity with no wind. Changing meteorological conditions, proximity to meals, presence of tension or excitement all change the demands on our cardiopulmonary and muscular systems. The machine back in the lab has no answer for this. The body has. Perceived exertion accepts those variables and thousands more, inserts them into our whole body computer and comes up with the answer—the proper pace.

The animal and athlete have always operated this way. The animal especially. No horse ever ran himself to death without a jockey on his back. And no horse would make it to the 7:14 in the morning if he didn’t feel just right doing it. Dependence on machines and devices eventually deprives us of the functions—intuition, instinct, body wisdom—for which they are substitutes. It is a major error to use

instruments and gadgets as replacements for the natural powers of the whole man moving through and reacting with his environment.

The whole man not only perceives exertion, he perceives exasperation. He not only registers breathing and pulse, cardiac index and muscle lactic acid, oxygen uptake and core temperature; he records anxiety and hostility, anger and fear, guilt and frustration.

It is there that coronaries are bred.

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In the 14th century, Tibetan physicians gave up on surgery. Disease, they said, is caused by demons, environment, behavior and foods. But mostly one’s health is dependent on having a good karma—a combination of a good life style and the expression of the real self in the sum total of thoughts, words and deeds. A bad karma causes illness.

No better description exists for the cause of the 20th century plague, coronary artery disease: the demons of frustration, anger, guilt and failure; an environment of intolerable stress; the behavior of repression, avoidance and denial; a diet to satisfy the emotions. All these bring with them bad karma and breakdown of essential body functions. Disaster must occur sooner or later.

If you have had a heart attack, it may indeed be a blessing in disguise. Chances are the pre-heart attack you was living a destructive, disrhythmic life, out of sync

with the real you that was trying to develop. The odds are great that you were

“Heart and Mind”

Michael Hughes

overweight, underexercised and functioning at about 20% of your physical, mental and spiritual capacity. You had, in effect, a bad karma.

Now is the time for you to make a fresh start. First, analyze and eliminate those inner tensions and conflicts that previously complicated your life. Start to develop your real potential. To live at the top of your powers, you must reach the best physical fitness possible for you. This will require a good conditioning program on a daily basis. Your doctor can counsel you on when you can start and on the kind of exercises suitable to your present situation.

Your doctor can tell you about aerobic exercises. He can explain that they stimulate your heart and lungs to increase their function to meet your muscles’ demands for more oxygen. He can point out that this is a pay-as-you-go system which takes in whatever oxygen is needed for the task—tasks such as golfing, swimming, jogging, cycling, rope skipping and the rest of those low-pressure endurance activities.

The doctor can tell you about the exercises, but you have to pick the one that goes with your karma—one for which you are physically and psychologically equipped.

This exercise will give you a new and truer image of yourself. It will also give you a fresh understanding of your strengths and weaknesses, and with it a new attitude towards things that would dilute your efforts and change that good feeling you are getting. Problems with smoking, drinking and diet will disappear of their own weight.

Eventually, you will be in much better condition than you were before your heart attack, but that’s not all. Your exercise periods will provide time for the examination of the life-style that preceded this illness, to rearrange your priorities, to discover yourself.

Your heart attack could be life-promoting instead of life-threatening. It’s all in how you handle it. And what your karma is.

By the age of 50, wrote Camus, a man has the face he deserves. And despite my long nose, overbite and receding chin, I accept that judgment. My face says a great deal about who I am and what I’m doing about it. But it is not my face that tells me I am master of my fate and captain of my soul. It is my pulse.

At any age, a person has the pulse he or she deserves. I regard my heart rate as my own responsibility. Like my nose and my overbite, there are limits to its perfection. But like my face, the obstacles to that perfection are not my genes but the seven capital sins.

The pulse tells me three different things about my body and its capabilities. This information comes from three different aspects of the pulse: (1) the resting pulse rate; (2) the exercise pulse rate; (3) the post-exercise pulse rate.