Medicine and Science in Ultra-Endurance Sports Day 2

I started Day 2 with a nice 6 mile run, same course as the day before and was a great start to the day.  Below I will summarize the lectures for the second and last day of the conference.

Injury Pattern in 100-mile Ultramarathoners- Morteza Khodaee, MD, MPH    Univ. of Colorado.

The main areas of injury during the race include:

• Dermatologic- blisters and subungal hematomas (black toenails)
• Musculoskeletal-patellofemoral pain (7-33%), Achilles tendinopathy (8-19%), knee/foot/ankle tendinopathy (<10%), IT band syndrome (7%), stress fx (5-10%), plantar faciitis (8-10%)
• Respiratory-asthma exacerbation.
• Excess hydration/hyponatremia
• Rhabdomyolisis
• Trauma
• High altitude illness
• Heat-related illness
• Exercise-associated collapse
• Gastrointestinal problems-predominately nausea and vomiting.
• Vision problems

During training there are less dermatologic and metabolic problems but overuse injuries. In an extensive survey, 77% ultra runners reported exercise-related injuries in the past year. However, compared with the general population, ultramarathon runners appear healthier and report fewer missed work or school days due to illness or injury. Take home point: You are likely to get injured while training for an ultra.

Key Medical Issues at Ultra-endurance Foot Races  Brian J. Krabak, MD   Univ. of Washington
Brian went on to contrast the overall injuries and illness rates in marathon races, Ultramarathons, and Multiday Marathons (Stage Races).  In marathons, the predominant problems were medical with less musculoskeletal and skin problems.  In Ultras, the musculoskeletal problems were more prominent and less so the medical issues. In stage races, the skin problems were the overwhelming majority of the issues encountered. Another topic covered was Postural Hypotension (low blood pressure while standing) which in one study occurred in 85% of runners admitted to the medical tent after a race.  The cause is an abrupt cessation of lower extremity muscle pumping actions combined with cutaneous vasodilatation.   This in turn results in venous pooling of blood in the lower extremity and low blood pressure.  The presentation is the collapse of the runner after crossing the finish line, dizziness, nausea, confusion.  Treatment is to lie down, elevate legs, and orally hydrate.  Prevention is by hydrating and WALKING after crossing the finish line, however there are no lasting effects except to your pride. Next, he discussed heat exhaustion and heat stroke. Heat exhaustion is seen with a normal to slightly elevated rectal temperature (102-104 F) with skin still moist.  It causes an inability to continue to exercise or collapse, weakness, fatigue, muscle cramps, nausea, irritability, agitation, and mild confusion. Treatment of heat exhaustion is removal from competition and cooling with ice packs or immersion of whole body in ice water.  Heat stroke is more serious and can cause collapse with severe mental status changes.  The skin may be hot and dry and the rectal temperature can exceed 104 F.  Treatment is with ice packs or immersion of whole body in ice water and transport to hospital.  On the opposite end of the spectrum, he discussed hypothermia where core temperature in a cold environment decreases to less than 89 degrees F.  Mild hypothermia can cause rapid heart rate, hyperventilation (rapid breathing), mental status changes, and shivering.  Moderate hypothermia causes slowed heart rate, hypo-ventilation (slow breathing), CNS depression, and loss of shivering.  Severe hypothermia causes pulmonary edema (fluid in lungs), slow heart rate, low blood pressure, coma, and life threatening ventricular arrythmias. Take home points: train and plan for the different environmental conditions to finish race safely.

Medical Needs at Ultra-Endurance Footraces: Race Director's Perspective    Craig Thornley, Race Director  Western States Endurance Run
Craig gave a really nice lecture about the philosophies of the medical aid at an endurance race from the race director's perspective.  One approach is to treat runners like horses whereby medical personnel are given supreme power to pull a runner from a race even when the runner wants to continue.  The other extreme is to let the runner make their own decisions with regards to whether to continue or to drop.  A natural tension exists between these two extremes and the sweet spot is likely somewhere in the middle.  Craig said the goal should be for the runners to view medical volunteers as allies and not to be avoided for fear of being pulled from the race.  Take home point:  In an ultra, the decision to drop should be made by the runner with the advice of qualified medical personnel.

The rest of the day was spent with case studies about medical problems with runners.  The first case was an elite runner who had a severe asthma attack at mile 30 and required bronchodilators (Albuterol)  and improved with subcutaneous epinephrine.   The second was  about a runner who had acute cholecystitis while running the Tahoe Rim Trail.  The third was about a case of high altitude pulmonary edema in Leadville 100 at Hope pass (12,600 feet).  Next was a case of rhabdomyolysis in a physician who improved with hydration and completed the race. (hope that wont be me).  They discussed a horrible fire in Australia in 2011 which happened during an ultra, and a physician who was there spoke about it.  The last case was of a runner in 2013 who after dropping at mile 85 developed seizures on the way to the finish by car.  He had severe hyponatremia and was hospitalized for 4 days.  He has fully recovered, has no memory of the events and is back to run the 100 miles again.  He was at the conference and answered questions as best as he could remember of how much water he drank that may have caused such a severe hyponatremia.

Overall, an excellent conference, and they will be repeating it next year on race week of Western States for anyone who may be interested in attending.  I highly recommend it.

Medicine and Science in Ultra-Endurance Sports Conference Day 1

I started my first full day in Squaw Valley with a nice and easy 6 mile run in the AM.  Then I had the pleasure of attending a fascinating series of lectures in a conference titled, "Medicine and Science in Ultra-Endurance Sports".  This is the first time this event has been held and is sponsored by the Wilderness Medical Society.  I wanted to share the main bullet points from all the lectures which were all very good.

Cardiac Function in Ultra-marathoners- David Oxborough, PhD   Liverpool John Moores University
Dr. Oxborough went on to describe several acute and chronic effects on the heart in response to long distance running.  The chronic effects include eccentric hypertrophy of the Left ventricle (the main pumping chamber) and increase in the chamber dimension with normal function maintained.  This as opposed to a sick heart which will enlarge and  have decreased function.  The normal adaptive enlargement is to allow for more cardiac output during exercise.  He also observed in athletes that the Left atrium and right atrium (the top chambers) enlarged proportionally more than the left ventricle.  In the acute phase, in other words, right after the race, there appears to be significant Right ventricle enlargement and some decrease in function which improves after 1 day.  When bio markers of heart muscle injury were measured after an ultra, these were found to be slightly elevated.  This suggests microscopic heart muscle damage.  There also have been reported animal studies which show increase in fibrosis in the right ventricle and may predispose these individuals to arrhythmias.  (abnormal heart rhythms).  The most common appears to be atrial fibrillation which a few studies have shown has an increased incidence in long distance runners. He reported that all the studies do not seem to indicate an increased incidence of coronary artery disease (the cause of heart attacks) in long distance runners.  Take home point: Endurance training and competing has effects on the heart but these are not pathologic. Keep running.

Neuromuscular Fatigue: Lessons from Extreme Sport- Guillaume Millet, PhD  University of Calgary
Dr. Millet went on to differentiate the causing several elegant studies of maximum voluntary contraction before and after the ultra he showed that central fatigue is more of a factor than peripheral fatigue.  The cause of mental or central fatigue may be related to excess serotonin accumulation in the brain, or the so called "serotonin hypothesis".  There was no difference between men and women in these studies.  Take home point: fatigue is mostly in your head.

Effects of Ultra-Endurance Exercise and Carbohydrate Restriction on Membrane Fatty Acids, Inflammation, and Insulin Sensitivity- Stephen Phinney, MD, PhD  UC Davis
This lecture reinforced what has lately been the idea that a high carbohydrate diet may not be the best approach to training and participating in endurance events. As fuel, a typical 70-75 Kg athlete has 2,480 Kcal stored as muscle and liver glycogen, whereas that individual has 110,700 Kcal in the fat stores.  In order to become efficient at burning fat, a ketogenic diet (low carb, high in Fat and Protein) will dramatically enhance the capacity of fat oxidation.  This results in a reduced dependence on glycogen.  Of note, it takes weeks of adaptation when one goes on this diet before performance is restored.  The changes are at the mitochondrial level in the muscle and reduced insulin sensitivity. Take home point:  Consider altering from the conventional wisdom that carb loading is good and switch to a ketogenic diet. (paleo)

Gastrointestinal Distress in Ultramarathoners-  Kristin Stuempfle, PhD
A very common occurrence in running ultras, GI distress occurs in 37-60% of runners in 67-161 Km races.  In 161 Km races, it is the number one reason for dropping out. For one, as the cardiac output increases, there is decreased blood flow to gut and kidneys to shunt to the exercising muscles.  The causes appear to be various and include esophageal motility disruption and lower esophageal sphincter tone resulting in heart burn.  In the stomach, intense exercise causes delayed gastric emptying and this results in bloating, cramps, nausea, and vomiting. (lovely).  In the intestines, absorption of sugar and water is decreased and this can cause diarrhea.  Interestingly, they analysed what people ate and the effects of GI distress with the finding that consumption of more FAT seemed to cause fewer symptoms.   Take home point:  You are likely to have GI symptoms when you do an Ultra. Fluid and fat consumption may protect  you from it.

Sodium Supplementation, Drinking strategy and Weight change in a 100-mile Ultra- Marty Hoffman, MD  UC Davis

Marty mostly talked about taking salt tablets during the race and weight changes which are observed in the runners. He had a slide about the recommendations based on the weight, which are as follows:

• Weight up, stop drinking until you pee off the excess.
• Weight down, drink.
• Mental status changes, drop and get medical help.

Take home point: Good idea to take salt tablets and drink water.

Barefoot/Minimalist Shoe Running and Foot Strike Pattern- Kevin Kirby, DPM, MS California School of Podiatric Medicine
Dr. Kirby began with a historical perspective on shoes and running shoe design. He showed how lightweight, thin-soled running shoes have been continuously available to runners for the past 40 years.  In the 70's they were called "racing flats" and were nearly identical to what today are called "minimalist shoes".  In an analysis of barefoot running, he showed that they increase stride frequency.  Also, contact time, stride duration, and flight times all decrease in barefoot running. .  Lastly, barefoot runners shorten stride length possible to avoid heel impact. He reminded us that "over-striding" has long been known to cause inefficient running form and reducing stride length often seems to lessen injury risk in runners. Lastly, he presented a study of 103 runners over 12 weeks which showed that running in minimalist footwear appears to increase likelihood of experiencing an injury. The speaker then spoke at length about heel striking vs. forefoot/midfoot striking, and found no significant difference in frequency of running injuries between the two.  However, there was evidence that CHANGING foot strike may cause injury. He also mentioned the Hokas, which he said were good and recommended changing shoes during the training week to reduce risk of injury.
Take home point: If heel striking, don't worry and don't try to change it.

Exercise-Associated Hyponatremia (EAH)- Tamara Hew-Butler, DPM, PhD  Oakland University.
An important topic for all marathon, Ironman triathletes and ultrarunners, hyponatremia can be life threatening. A low serum sodium can be caused by dilution in that you take in too much water combined with depletion of sodium via electrolyte losses in sweat or vomit. An important contributor to developing EAH  is the hormone ADH (anti diuretic hormone) also called AVP (arginine vasopressing).  Its function is to prevent water from being released in the urine, it concentrates the urine.  In an ultra or marathon, AVP levels are high during and post race which contribute to the dilution of sodium. Affected individuals can gain or lose weight and as such, body weight changes become less reliable indicators of fluid balance as race distance progresses.  When sodium is low symptoms can be vague at first but can progress to mental status changes.  The diagnosis is confirmed with a blood test and is treated with hypertonic saline.  Take home point:   Exercise-Associate hyponatremia (EAH) is bad, recognize the symptoms and treat urgently.

Rhabdomyolysis and Acute Kidney Injury - Robert H. Weiss, MD  UC Davis
Rhabdomyolysis is skeletal muscle damage that causes release of myoglobin and other muscle components into the blood stream and can in severe cases cause kidney failure to the point of needing dialysis.  It is characterized by severe muscle pain and inflammation.  In 2009, they reported on 5 cases of rhabdomyolisis and four had significant injuries that limited their training, so they came to the race under trained.  They pushed through despite being in severe pain. \Other predisposing factors include dehydration and hyperthermia.  Medications such a statins to treat cholesterol may increase risk but not proven, recommended to hold this medication before an endurance event. Take home point: If you are hurting a lot, you may need to quit.


Overall, an excellent day of lectures, if you are still reading this, I hope you get something out of it.  Tomorrow the lectures are less scientific and more practical.  I hope I still have the endurance to write it all again.

Western States Training and preparation

Western States 100 trail

Training for Western States

Western States endurance run race week has finally arrived and I am anticipating a great adventure on June 28, 2014.  It has been a dream 2 years in the making to arrive at the starting line of this prestigious event.  I came to Squaw Valley early to make the most of my experience and attend a medical conference Tuesday (6/24/2014) and  Wednesday (6/25).  The meeting is called "Medicine and Science in Ultra-Endurance Sports"  and I will be posting about what I learn that may be interesting to the endurance athletic community.  Later in the week, I intend to post about the race week activities.  My last post about Western States will be a post race report.

My training in earnest began on Jan 1 with base building.  I decided to hire a coach and he sent me structured workouts starting on the first week of January.  I did 6-8 miles on weekdays with longer runs on Saturday.  On Sundays, I did "tempo" longish runs with "tired legs" from Saturday's run.  During the early training weeks, my coach had me do "hill repeats".  These consisted in finding a stretch of trail with 10-15% grade and climbing as fast as possible for 3 minute intervals.   I would rest for 1 minute and then descend as fast as possible back down. Rest another minute and repeat.  Initially, I did 4 hill repeats and when it got closer to the race I was up to 6 hill repeats. I did the repeats on a Jeep road off Robinson St. on the way to crazy cat mountain.  It was not ideal as it was very rocky and technical, but it is pretty accessible. The weekly mileage was about 40-50 in the early weeks and by the middle of May, I was up to 100 miles in a week.  This was accomplished with twice daily runs on weekdays (AM 9 miles and PM 6 miles). The Saturday long runs were at the most 40 miles followed by 10 tempo miles on Sunday. 

In March, I ran Caballo Blanco 50 mile Ultra for which I did not taper and completed that race in 12 hrs and 30 min.  My recovery from that race was fairly quick and I was able to run as early as Wednesday after the race. 

Everything was going well until Saturday, May 17 when I was scheduled to run 18 miles and decided to go from the Lost Dog trails up to Tom Mays and up to North Franklin Peak and back.  In the descent from North Franklin, I got a bit too enthusiastic and went down too fast. I was jumping and heel striking and came away from the run with a sore ankle.  The pain was predominantly in the calcaneus or heel bone. I iced it overnight and it felt better.  Unfortunately, on Sunday, I was signed up to do a 5K race with my children and I was racing my oldest son, Javier, who is 16 yrs old.  The whole run, I was in pain, but I did it in 21:55 (7:18 min/mile).  I lost to my son who ran it in 19:35 but the effort cost me dearly. I had severe pain and was unable to walk, much less run.   I self diagnosed clinically, since I did not have any imaging studies, with a calcaneus stress fracture or pericalcaneus bursitis with ligament strain.  The treatment is not to run and allow time to heal.
I had been scheduled to go to a Western States training camp over the Memorial Day weekend and had to cancel my trip.  Instead, I went to the pool, learned to enjoy the elliptical machine and started cycling again. I also went for the first time to hot yoga sessions which were fun and good for heat acclimatization.   For 3 weeks, I could not run at all.  I bought some Hoka shoes which are like "moon shoes" with a lot of heel cushion and started walking with them.  I did training walks in the 100 degree heat of the afternoon with the hydration vest to get some heat training.
With 3 weeks to go for the race, I started slowly to run again on the road with the Hokas.  I did 2 miles, then 4, and by Wednesday, I was running 6 miles with Run El Paso Club.  My distance was up to 51 miles at its peak before I started tapering for the race. My last long run was up to McKelligon Canyon for 15 miles on Saturday and then 6 miles on Sunday before leaving for Squaw Valley, California on Monday (6/23).

Race preparation
I have been meticulously studying the race course since I have never done this race before and did not get to attend the training camp over memorial day weekend.   I have enlisted a crew person recently, but I had been making plans without crew.  There are 10 drop bags allowed along the course including at the finish line in Placer High-school in Auburn.   I made use of a race pace/split calculator from Climbers.net, the link is here:  Western States 2012 race calculator  I found this site helpful since there are so many climbs a consistence pace is hard to maintain.  I copied onto an Excel spreadsheet and will be using this to guide my slow pace and keep track of the aid stations and drop bags.

Projected pace for Western States 100

Western States course profile

Additionally, I read a great review of the course on IRunFar.com by Joe Uhan with the ominous title, "The Western States Killing Machine".   My race plan is to go slow from the beginning to save by legs during the long downhill sections to have energy left to go the last 20 miles at a decent pace.  

As I get settled here in Squaw Valley, my plan for tomorrow is to attend the conference and at the end of the day, I will blog about what is discussed. On Thursday and Friday, will post about the pre-race activities, including the Beer mile on Thursday.