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.