Journal of the American Medical Athletic Association

Volume 29, Number 3 Fall/Winter 2016 A Tough Challenge Ahead FOUNDER Ronald M. Lawrence, MD, PhD Most AMAA members and many non-current members have heard the news that the BOARD OF DIRECTORS Cathy Fieseler, MD, President Boston Athletic Association (BAA) has declined our proposal to continue as a fundraising Charles L. Schulman, MD, Immediate Past-President non-profit organization at the Boston Marathon. It was a blow to the organization financially Douglas J. Casa, PhD, ATC, FACSM and a loss to the many past and current members who have run and volunteered at many S. Mark Courtney, PA-C Boston Marathons. Mark Cucuzzella, MD, FAAP Ronald S. Dubin, MD Here is the best explanation of the recent events. Each summer we submit a request to be a Ronald M. Lawrence, MD, PhD, charity partner with the BAA. It is never a sure thing in event fundraising or revenue production Member Emeritus when you do not control the event or source of income. It was always our goal to show the BAA Noel D. Nequin, MD, FACSM, FAACVPR, that AMAA, its members, and our events at the Boston Marathon added value to the BAA and its Member Emeritus COL Francis G. O’Connor, MD, FACSM marathon. We never took it for granted. Yet, in June of this year, we found out we would have Chris Troyanos, ATC to compete with other nonprofits to be an “official charity” of the Boston Marathon in order to HONORARY DIRECTORS receive “invitational entries” to raise funds at the marathon. Essentially, our one-on-one deal Marv Adner, MD with the BAA was not going to be renewed. By the end of July, we put forward a proposal that we Judi Babb felt was worthy and beneficial to the BAA and the greater community of the Boston Marathon. Walter M. Bortz II, MD It came down to (in my best guess) that our NATIONAL RUN A MILE DAYS campaign was not Ken Cooper, MD focused enough on the Greater Boston community. EXECUTIVE DIRECTOR AMAA has never been stronger as a professional non-profit division of American Running. David Watt Our sports medicine continuing education symposiums are well-respected and have grown MANAGING EDITOR in attendance. Members have raised thousands of dollars that have benefited our NATIONAL Barbara Baldwin, MPH RUN A MILE DAYS campaign. The “Run a Mile” effort started with a few schools as test pro- BOOK REVIEW EDITOR grams in a few towns and counties near staff and members. It has grown virally to where Paul J. Kiell, MD we have over 36,000 students in 24 states running the mile each spring. The enthusiasm of TALKING ABOUT TRAINING EDITOR ARA and AMAA members along with school teachers and administrators has been infectious. Douglas F. Munch, PhD Feedback to lead PE teachers and to our staff has been heart-warming. Kids love learning CONTRIBUTING WRITER how to train and run the mile. Along the way, the young kids and youth have learned that Jeff Venables staying active through running is important year-round. MEETING COORDINATORS Discussions in the classrooms have expanded to focus on better eating habits too. AMAA Judi Babb Barbara Baldwin, MPH has inspired these young runners, and in turn, given new meaning of “giving” back to a com- munity for our members. EDITORIAL ADVISORY BOARD Brian B. Adams, MD We have a tough road ahead with major challenges. We are seeking new financial part- Donald B. Ardell, PhD ners and other avenues to raise funds. Membership and medical meetings are not enough Robert Bice, Jr., MD, FACS to sustain our nonprofit organization. We are looking at all options to maintain our sports Paul E. Casinelli, MD medicine symposiums at the Boston and Marine Corps Marathons. Both have been sustain- George M. Dallam, PhD Edward R. Feller, MD able in the past and we are looking at the best way to keep other elements of AMAA intact. Lawrence A. Golding, PhD, FACSM What can each member do? For one, find others to join and become active in AMAA. Find Steven J. Karageanes, DO friends in your community or town who would be interested in bringing a RUN A MILE DAYS John M. Levey, MD program to an elementary or middle school in that town, city, or county. Then find ways to Steve Morrow, DDS Douglas L. Noordsy, MD raise funds to make that MILE DAYS event happen. It is roughly a $5,000 goal per school of Edward R. Sauter, MD, PhD 500 to 600 students to hold a RUN A MILE DAYS campaign. Each school starts training in late Walter R. Thompson, PhD winter or early spring and holds the MILE DAYS event in May, some in early June. Bruce Wilk, PT, OCS We all have faced major challenges in life. For some, like me, it was advanced cancer. For The American Medical Athletic Association (AMAA), others it may be the end of a job or in the case of ARA and AMAA, a financial loss. We may professional division of the American Running Association, was founded in 1969 by Ronald M. Lawrence, MD, PhD, have to make changes to survive, but we can do just that—survive. All of us have to do our to educate and motivate fellow physicians to disseminate part to overcome the challenge at hand. We can do it. information about exercise and nutrition to their patients, thereby enhancing their quality of life. The AMAA Journal is a peer-reviewed publication. Best regards, Opinions expressed in the AMAA Journal are not necessarily Dave Watt, Executive Director endorsed by AMAA. Address editorial, membership, advertising and change of address information to AMAA, 4405 East-West Highway, Suite 405, Bethesda, MD 20814-4535, TEL: 301-913-9517, FAX: 301-913-9520, E-mail: [email protected], www.amaasportsmed.org.

2 AMAA Journal Fall/Winter 2016 AMAA PREMIER MEMBERS

The American Medical Athletic Association wishes to thank those members who have contributed to the organization beyond their annual dues. This list reflects membership upgrades received from August 1, 2015 to November 30, 2016.

OLYMPIAN ($250) SUPPORTER ($100) Mary C. Boyce Sal Barbera Julius S. Brecht Matthew Barnes Charles (Scott) Clark Christianne Bishop Harry Daniell Bill Borowski Ronald Dubin Walter M. Bortz, II ± Edmond G. Feuille, Jr. Thomas Boud Cathy Fieseler* ± Brad Carmines Wade Gaasch Steven D. Coffman Message from the President ...... 4 Scott Glickman James Culpepper Fawwaz Hamati Kathleen Doughney How Curiosity Killed the Cramp: Jeffrey Hawkins Michael S. Doyle Emerging Science on the Cause and John Howick Robert Erickson Prevention of Exercise-Associated Timothy Lepore Joseph M. Gaffney Muscle Cramps...... 5 Francene Mason John Geren Bob Murray, PhD, FACSM John McAuliffe John W. Gilpin Steve Morrow* ± Bernard Gitler Psychological Effect of Injury on Terry Murphy Jeff Godin the Athlete: A Recommendation for Robert A. Niedbala* ± Steven Grufferman Psychological Intervention ...... 8 William Paronish Michael Hamrock Shelly Sheinbein, MS Daniel Pereles Beverly Handy Richard Prokesch Dexter Handy Should You Change an Athlete’s Frank J. Rodriguez, Jr. Allan Katz Natural Running Form? ...... 11 Charles L. Schulman Brian Y. Kim Thomas C. Michaud, DC Robert Sholl James M. Larson Michael Solinger J. Mark Lawson Runners of Yesteryear ...... 14 Joseph L. Verdirame Robert B. Lee Paul J. Kiell, MD Joel B. Weber Frank Massari, Jr. Philip Zitello Ronald H. Miller Book Review: Patrick J. Hogan Robert P. Nirschl Swim: Why we Love the Water, Floyd Okada ± Blue Mind, and PATRON ($150) Mark Rubenstein Swimming in the Sink ...... 16 Larry Boies, Jr. Robert A. Sabo Douglas F. Munch, PhD and Paul J. Kiell, MD Phil Filbrandt Toussaint G. Toole William Kraus Clay Whiting Member Profile: Tristram C. Kruger John Zinkel Mark Lavallee, MD, CSCS, FACSM Franklin G. Mason Valerie Zughaib Overcoming Early Obstacles and Michael W. Moats Paying It Forward ...... 18 Jeff Venables * Contributions surpass Olympian level ± Life Member making contribution at the level of Premier Member

To become an AMAA Premier Member, please go to www. amaasportsmed.org and click on “Join AMAA.” The funds from this program help support the AMAA running medicine awareness campaigns and the American Running Association’s signature national outreach campaign event National Run A Mile Days held annually in May.

AMAA Journal Fall/Winter 2016 3 The times they are a changing…. Message As AMAA Executive Director Dave Watt stated in “Front of the Pack,” most of you know that from the the American Medical Athletic Association did not obtain charity entries for the 2017 Boston Marathon. What you might not know, however, is President that these entries and the fundraising dollars they generated were a major source of funding for the NATIONAL RUN A MILE DAYS campaign. This is the organization’s annual program promoting prompted many attendees to change their own fitness in elementary and middle school-aged lives, me included. That speaks volumes! children through running. Obviously, our loss of Another meeting to consider attending is our entries creates a major challenge to continuing sports medicine symposium held annually in this youth program. conjunction with the Marine Corps Marathon. Attendees work with ultrasound machines at Children now have a shorter life expec- The October meeting kicked-off a new three- AMAA’s 2016 Sports Medicine Symposium at the tancy than their parents due to diseases related year partnership between AMAA and MedStar Marine Corps Marathon. to obesity and inactivity. This is unacceptable Sports Medicine. As a result, we moved from our and preventable. Promoting the simple act of decade-long location at Virginia Hospital Center training for and running a mile to school-aged in Arlington to the Georgetown University School membership program by choosing to become a children can be a life changing event for many of Medicine, my alma mater. It was a great one- Supporter, Patron, or Olympian. Thank you. kids who would otherwise be in front of a screen. day meeting with lectures providing practical We also need to grow our membership num- Promoting NATIONAL RUN A MILE DAYS (www. information for the clinical setting and field-based bers. You have been steadfast in your commitment runamile.org) to schools in your area and keep- activities, as well as a variety of hands-on work- to AMAA, something the Board of Directors greatly ing your ears and eyes open for sponsorship shops. Attendees of this meeting are also invited appreciates, but we also need the addition of more opportunities can help keep this program alive. to run the race through entries we receive, or young members for the organization to survive As we move forward into 2017, we still plan to provide volunteer medical care for additional and grow into the future. If you work with students host the 46th Annual Sports Medicine Symposium Category 1 CME credit. or residents, please consider promoting AMAA to at the Boston Marathon in April. This has been an So, where do we go from here? We will strive them. If you would like organizational materials outstanding meeting and I hope many of you will to continue offering outstanding symposiums to share, contact Barbara Baldwin at bbaldwin@ attend, even if you aren’t running the marathon and encouraging the development of grass-root americanrunning.org. (register at www.amaasportsmed.org). Meeting youth running programs nationwide. But we I am working with executive director Dave attendees always comment on the outstanding need you, the members of AMAA, to help us in Watt and the Board of Directors to explore options speakers and topics each year and, in my opin- our efforts. Donations are greatly appreciated that will allow AMAA and its parent organization ion, what is most remarkable about the meeting and will be put to good use. In our most re- the American Running Association to thrive in is that it doesn’t just impact patient care. The cent membership renewal mailing, many of you future years. We have talked about hosting a run- information gleaned from the presentations has stepped up your support through our Premier ning camp, continuing our meetings at the Boston and Marine Corps Marathons, and possibly even expanding our meeting venues. We may also ex- plore opportunities for sponsorship to sustain the organization and our charity program. This will be a marathon undertaking and we welcome input and assistance from our members. Please maintain your membership and consid- er making a donation to the organization by going to www.amaasportsmed.org and clicking on the “Donate Now” button. Promote the organization to medical professionals, especially young health care workers. Promote the running program to your local schools. Read the AMAA Journal and check out the website regularly. Please be an ac- tive member of AMAA so the organization can continue to be viable and productive.

Keep running. Caldwell Esselstyn, Jr., MD, author of Prevent and Reverse Heart Disease, captivates the audience at Cathy Fieseler, MD, AMAA President the 2015 AMAA symposium in Boston. 4 AMAA Journal Fall/Winter 2016 How Curiosity Killed the Cramp: Emerging Science on the Cause and Prevention of Exercise-Associated Muscle Cramps

By Bob Murray, PhD, FACSM

Rod MacKinnon and Bruce Bean are electrolyte replacement, stretching, pickle juice, experienced sea kayakers who don’t allow even mustard, etc.) (15). blustery winter weather to stop them from long EAMCs are currently thought to be of paddling trips off the coast of Cape Cod. Wet neurogenic origin, possibly involving persistent suits, cockpit skirts, and constant paddling inward electrical currents (PICs) in the keep them warm enough in frosty conditions, dendritic tree of the spinal motor neurons, although they’ve learned firsthand that muscle perhaps promoted by a temporary disruption in cramps are not only a major nuisance but can be the balance of input from muscle spindles and life-threatening. Balancing in a needle-thin 17- Golgi Tendon Organs, which would normally act foot long sea kayak miles from shore as wind, to prevent too much tension in the tendon and waves, and cold conspire to wrench the paddle muscle fibers. In turn, these strong ion currents from your hands is simply not a good occasion to in the membrane are known to lead to changes experience cramps of any sort. in excitability and alter discharge patterns of the MacKinnon and Bean are long-time friends motor neurons, sending rapid bursts of action with overlapping professional interests. Both potentials down the axon to cause contraction of are neuroscientists, MacKinnon an MD with a muscle fibers (8). In the case of cramp-sensitive professorship at Rockefeller University and Bean skeletal muscles, individual motor nerves in the a PhD professor at Harvard Medical School. (In spinal cord control the contraction of hundreds 2003, MacKinnon was awarded the Nobel Prize or—in large muscles such as the quadriceps and in Chemistry for his research on the structure gastrocnemius muscles—over one thousand and function of potassium ion channels.) Both individual muscle fibers. A single motor neuron individuals cramped almost simultaneously and the muscle cells it innervates are referred on a kayak trip; their subsequent conversation to as a motor unit. Uncoordinated contractions naturally turned to the issue of cramping. They of individual motor units can result in localized were curious about what was known about the fasciculations (twitching) that can sometimes cause of muscle cramps and what remedies were be observed under the skin, especially during available. They dug into the literature and quickly or after strenuous exercise. Repeated muscle realized that the cause of muscle cramps—as well twitches often occur before the onset of muscle neurons, perhaps coinciding with a simultaneous as effective ways to prevent and treat cramps— cramps, with simultaneous and continuous reduction in inhibitory input from afferent were unclear and not thoroughly researched. discharges of several motor units resulting in receptors such as Golgi Tendon Organs (18). Exercise-associated muscle cramps full-blown muscle cramps (11,15,18). For many Regardless of the trigger for EAMCs (EAMCs) occur during physical activity and are athletes, EAMCs can be an infrequent nuisance (fatigue, dehydration, etc.), if cramps are of characterized as “… a sudden, involuntary, during training and competition, while others neurogenic origin, interventions that decrease painful contraction of a muscle or part of it, self- suffer from debilitating cramps numerous times persistent inward currents and motoneuron extinguishing within seconds to minutes and … each week. For those cramp-prone athletes, hyperexcitability may prevent EAMCs from often accompanied by a palpable knotting of the finding a way to prevent or quickly treat EAMCs occurring or reduce their severity. This concept muscle” (18). EAMCs afflict millions of athletes, can mean the difference between continuing the is supported by the observation that ingestion of workers, soldiers, and fitness enthusiasts, who sport they love or quitting out of frustration. pickle juice significantly reduces the duration are forced to alter or cease physical activity when Evidence for a neurogenic origin of EAMCs of electrically induced muscle cramps (14). the cramp strikes and then deal with subsequent includes the observation that cramp-prone The consumption of pickle juice (1 ml/kg BW) post-cramp soreness (11). subjects have a lower threshold for the electrical immediately after the induction of electrically Although the exact cause(s) are not well stimulation of muscle cramps (1,13,16) and that induced cramp of the flexor hallucis brevis understood, numerous factors are thought blocking the motor nerve with certain drugs such muscle of the foot reduced cramp duration to influence EAMCs (15), including muscle as anesthetics decreases or abolishes electrically compared to the consumption of deionized fatigue, prolonged muscle contractions, induced cramping (17). In brief, it appears as water. This experiment suggests that the muscle damage, restricted muscle blood flow, though a variety of factors (triggers) may alter ingestion of pickle juice triggered a neural diabetes, dehydration, and hyperthermia (11). normal neuromuscular control, especially so reflex in the oropharyngeal space that activated This diversity of the factors associated with during intense or fatiguing exercise, leading to the spinal inhibitory neurons and reduced alpha triggering EAMCs may explain why a variety of development of persistent inward currents in the motoneuron activity to the cramping muscle, interventions, with mixed results, have been dendritic field of lower motor neurons sufficient lessening the duration of the cramp. attempted to suppress EAMCs (e.g., hydration, to exceed the excitation threshold of affected continued on page 6 AMAA Journal Fall/Winter 2016 5 Multiple studies of healthy human volunteers using electrically- induced cramps in one foot demonstrated that consumption of a small volume (< 2 oz.) of beverages containing various formulations of TRP channel activators was associated with statistically significant reductions in cramp intensity. continued from page 5 to various targets in the brain and brainstem, small volume (< 2 oz.) of beverages containing MacKinnon and Bean suspected that a including the locus coeruleus and the dorsal various formulations of TRP channel activators mouth-to-brain-to-muscle mechanism could be raphe nucleus. Neural projections from these was associated with statistically significant effective at preventing EAMCs. They hypothesized cell groups extend widely throughout the brain reductions in cramp intensity (EMG area under that activation of Transient Receptor Potential or and spinal cord, and activation of these efferent the curve); in some of these experiments the so-called TRP ion channels in the sensory nerves neural circuits in the spinal cord may prevent duration of cramp inhibition was found to last 6-8 of the oropharynx and upper GI tract could muscle cramps by decreasing PICs, thereby hours post-ingestion (9,21-23). The researchers reduce the hyperactivity of the motor nerves that restoring the normal activity of the motor hypothesized that the strong excitatory input sustain a cramp. TRP channels belong to a super- neurons involved in muscle cramping. produced by TRP channel activators increased family of membrane channels expressed in many In the hope that their initial observation might inhibitory tone in the spine (e.g., reduced PICs), cell types, including sensory nerve cells (19,24) benefit athletes with EAMCs and possibly patients resulting in a significant diminution of cramp involved in the detection of temperature, tastes, with frequent muscle cramps, MacKinnon characteristics via inhibition of persistent neural stretch, and pressure as well as noxious and and Bean started a company* to further their input to the affected muscle. This research has pungent chemical agents (12,20). Specifically, research and combat cramping. There are now now been presented at the last two American TRPA1 and TRPV1 channels are activated by several lines of converging evidence to support Academy of Neurology (AAN) Annual Meetings compounds contained in capsicum, garlic, the concept they developed that TRP channel (21,23) as well as the 2015 Congress of the and other pungent plant extracts (5,19). TRP activation by common natural compounds can European Committee for Treatment and Research channels allow cations such as sodium, calcium, prevent and treat muscle cramps by increasing of Multiple Sclerosis (ECTRIMS) (9). and magnesium to pass across membranes and the inhibitory tone in the spinal cord and thereby Another series of five studies used healthy, but are abundantly expressed in sensory nerves reduce lower motoneuron hyperexcitability. cramp-prone athletes as subjects (n = 139). The in the oropharyngeal space (see Figure 1), In experiments reminiscent of electrically athletes consumed a proprietary TRP-activator including the trigeminal (V), glossopharyngeal stimulating frog muscles in high school biology beverage within 30 minutes of their normal training (IX), and vagus (X) nerves that project directly class, multiple studies of healthy human sessions and recorded the frequency, duration, and indirectly to the solitary tract nucleus in the volunteers using electrically-induced cramps in and pain ratings associated with all episodes of lower brainstem, which in turn has connections one foot demonstrated that consumption of a cramping. Other training sessions were completed without any intervention or, with some subjects, Figure 1: A simple schematic of the sensory nerves innervating the oropharyngeal space. using a placebo control beverage. The results consistently showed a reduction in the frequency of EAMCs compared to baseline measures (i.e., cramps were prevented in some subjects.) In addition, the athletes reported a quicker return to training after a cramp episode (10). Researchers at Penn State University recently presented results showing that consumption of TRP channel activators reflexly decreases neural hyperexcitability, thereby preventing cramping (3). Their volitional, non-electrical cramp paradigm is a closer representation of what athletes experience when cramping during exercise. EMG recordings and other measurements were made before, during, and after each cramp episode. Again, consumption of the TRP-activator beverage significantly reduced the EMG area under the curve, consistent with inhibition of motoneuron activity in the cramped muscle. In addition, consumption of the beverage was associated with lower post-cramp muscle soreness ratings in the 20 minutes following the cramp (3), a response possibly due to the reduced intensity and duration of cramp contraction and related pain rather than cramp-induced muscle damage.

* FlexPharma, Inc. 6 AMAA Journal Fall/Winter 2016 It is possible that consuming a beverage that sufficiently activates TRP channels might not only prevent muscle cramps but also improve exercise capacity.

Several lines of research are now being pursued muscle cramps include intravenous electrolytes, 10. Passe DH. Exploratory data analysis: efficacy of a spicy beverage in altering the characteristics of EAMCs to better understand the cause of EAMCs and the apple cider vinegar, mustard, sedatives, anti- in athletes during normal training sessions. Private pathophysiological conditions that precede the seizure medications, and even pinching the upper communications, 2016. onset of overt muscle cramping. As pointed out, lip, but evidence of reliable efficacy is lacking 11. Katzberg HD. Neurogenic muscle cramps. J Neurol fasciculations or “muscle twitches” are commonly in most cases. Athletes are always well-advised 2015; 262:1814-1821. 12. Miller AJ. Oral and pharyngeal reflexes in the observed before overt cramping. How does the to follow current guidelines for hydration and mammalian nervous system: their diverse range in uncontrolled discharge pattern of a single motor nutrition to reduce the fatigue-induced risk of complexity and the pivotal role of the tongue. Crit Rev neuron suddenly reach a “flashpoint” to expand cramping. Stretching a cramped muscle is usually Oral Biol Med 2002; 13(5):409-425. 13. Miller KC, Knight KL. Electrical stimulation to neighboring motor neurons in the spinal cord? effective at releasing the cramp by activating the cramp threshold frequency correlates well with the Why is this phenomenon usually limited to a single afferent inhibitory influence of Golgi Tendon occurrence of skeletal muscle cramps. Muscle Nerve muscle? What are the mechanisms that prevent Organs, but athletes don’t want to have to stop, 2009; 39(3):364-368. 14. Miller KC, Mack GW, Knight KL, Hopkins JT, Draper the expansion and keep a cramp localized to a preferring cramp prevention over treatment. DO, Fields PJ, Hunter I. Reflex inhibition of electrically single muscle rather than spread ephaptically, induced muscle cramps in hypohydrated humans. directly across adjacent nerve fiber membranes, Bob Murray co-founded the Gatorade Sports Med Sci Sport Exerc 2010; 42(5):953-961. to neighboring muscles? Studies are underway 15. Miller KC. Rethinking the cause of exercise- Science Institute (GSSI) and served as its associated muscle cramping: moving beyond to address these questions and understand the director from 1985 to 2008. After departing GSSI, dehydration and electrolyte loss. Curr Sports Med Rep immediate and delayed consequences of muscle Bob founded Sports Science Insights, LLC, where 2015;14(5):353-354. cramping, as well as what other performance he consults for Flex Pharma, Inc., to identify 16. Minetto MA, Botter A. Elicitability of muscle cramps in different leg and foot muscles. Muscle Nerve 2009; and recovery benefits TRP activation might have qualified university scientists to conduct related 40(4):535-544. for an athlete. A particular focus of this research research projects and help in research design and 17. Minetto MA, Holobar A, Botter A, Ravenni R, Farina is the relationship to immediate and delayed the interpretation of results. D. Mechanisms of cramp contractions: peripheral or central generation? J Physiol 2011; 589(Pt 23):5759- onset muscle soreness, muscle damage and 5773. inflammation, and the important functional aspect REFERENCES 18. Minetto MA, Holobar A, Botter A, Farina D. Origin and of motor recovery. This promising line research 1. Bertolasi L, De Grandis D, Bongiovanni LG, Zanette GP, development of muscle cramps. Exerc Sport Sci Rev Gasperini M. The influence of muscle lengthening on 2013; 41(1):3-10. may provide a better understanding of the neural cramps. Ann Neurol 1993; 33:176-180. 19. Nilius B, Appendino G. Spices: the savory and mechanisms that degrade muscle performance 2. Chambers ES, Bridge MW, Jones DA. Carbohydrate beneficial science of pungency.Rev Physiol Biochem acutely and how the activity of certain neural sensing in the human mouth: effects on exercise Pharmacol 2013; 164:1-76. performance and brain activity. J Physiol 2009; 587 circuits may positively impact neuromuscular (Pt 8):1779-1794. 20. Paulsen CE, Armache JP, Gao Y, Cheng Y, Julius D. Structure of the TRPA1 ion channel suggests regulatory performance such as exercise capacity immediately 3. Craighead DH, Shank SW, Alexander LM, Kenney WL. mechanisms. Nature 2015; 520(7548):511-517. following treatment intervention and over time. Orally ingested transient receptor potential channel activators attenuate the intensity-duration of voluntarily 21. Short G, Hegarty BW, MacKinnon R, Bean B, In this respect, TRP channel activation may induced muscle cramps in humans (abstract). FASEB Westphal C, Cermak JM. 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AMAA Journal Fall/Winter 2016 7 Psychological Effect of Injury on the Athlete: A Recommendation for Psychological Intervention

By Shelly Sheinbein, MS

At one time or another during their sporting (5) long after they’re physically recovered. cause physiological changes including over or competitive activities, many athletes may suffer In this brief article, I will examine common arousal evident through increased heart rate, an injury that keeps them from participating for psychosocial responses to injury and describe generalized muscular tension, and guarding the duration of their recovery. If you have been several empirically supported psychological the injured site (9). Thus, an athlete who fears lucky enough to train without significant injury, interventions which have effectively reduced reinjury tends to develop a lack of trust in the it is still likely that you know someone who emotional distress, as well as improved physical injured site which can produce hesitance in has had an injury that requires some duration and mental outcomes for injured athletes. performance during rehabilitation and when of professional rehabilitation before they can returning to training and competition. Athletes’ train normally again. These serious injuries Reinjury Anxiety awareness of their substandard performance and rehabilitation are often accompanied by Reinjury anxiety is one of the most common can then lead to decrease in coordination, lingering psychological consequences which can psychological reactions experienced by injured muscle tension, and bracing or splinting impact the athletes’ well-being as well as their athletes (6), as well as the most commonly cited which are suggested to increase actual reinjury likelihood of returning to sport. reason presented by athletes for not returning occurrence (9). Overall, both psychological In the United States there are an estimated to sport post ACL surgery (7). Reinjury anxiety and physiological responses to reinjury anxiety seven million sport and recreation-related or fear of reinjury, both used synonymously contribute to athletes falling into a cycle of injuries per year (1), not including sport injuries within the sport injury literature, is defined as inactivity that may lead to reductions in body that may go unreported, such as sprains and an irrational and debilitating fear or anxiety that strength and flexibility, and can result in athletes concussions. According to the National Sporting physical movements will result in painful reinjury experiencing greater pain when active, thereby Goods Association, 521,578 people were treated (1). In a sample of 49 recreational-level athletes reinforcing the reinjury anxiety that perpetuates for bicycle related injuries. Additionally, 83% (Mage = 29.15 years) who had undergone ACL continued avoidance. of amateur or competitive runners experience surgery one year prior, Tripp et al. (1) found knee, ankle, and foot injuries which can hinder that athletes’ experiencing high reinjury anxiety Psychological Distress their quality of life temporarily or definitively reported having lower confidence in their ability In addition to reinjury anxiety, athletes can (2). Despite efforts to reduce the prevalence to return to sport (p < .01). Relatedly, in a experience depressive symptoms following injury of injuries with advancements in sporting sample of 62 athletes (32 men, 28 women ages (4). The severity of the depressive symptoms equipment, coaching techniques, and sport- 18 to 37 years) who underwent ACL surgery can vary based on the injury, limits to mobility, specific conditioning, sport and recreational three to four years prior, athletes reporting length of rehabilitation, and delay in the athlete injuries continue to increase over time (1). high fear of reinjury also reported their knees returning to sport or physical activity. Depressive When athletes are injured they experience not functioning as well as they did prior to their symptoms can arise soon after the injury which a range of emotions which are frequently injury (p < .05) (3). could be associated with frustrations due to more debilitating when they require longer Whereas previous research examining immobility, difficulties participating in everyday rehabilitation. For instance, Marcus Lattimore, reinjury anxiety has focused on athletes who activities, and feelings of injustice and shock a record-setting freshman of the year tailback received ACL reconstruction surgery, several associated with the injury. Depressive symptoms and Heisman contender for University of South researchers have speculated that fear of injury can also have a delayed onset and could be Carolina suffered a series of sport injuries is always present among athletes especially associated with feeling socially isolated, loss including a torn Anterior Cruciate Ligament following a serious injury (1). One can easily of skills or opportunities, and overall absence (ACL), dislocated kneecap, torn ligaments and imagine an athlete struggling with reinjury from participating in training or competition nerve damage. Despite countless surgeries and anxiety after a myriad of sport and physical which can contribute to loss of athletic identity rehabilitation he was chosen in the fourth round activity related injuries. For instance, a swimmer (10). Thus, an athlete who requires surgery by the San Francisco 49ers. However, after only who has gone through shoulder surgery may feel following sport injury may be more vulnerable a few days of practice he decided to give up anxious about returning to intense training or to depressed mood than an athlete who has less football due to pain and lack of confidence in competition or a cyclist who suffered a serious severe sport injuries because of the delay in his knees ability to function at the same level he accident while riding may feel hesitant about returning to play (1). had previously. There are many athletes ranging riding on the street and therefore ride with Additionally, athletes who report from novice to professional level and across a hesitance and less frequency. experiencing somatic symptoms (e.g., physical wide range of sports and recreational activities, Reinjury anxiety is associated with aches and pains associated with psychological who have suffered career ending injuries and psychological changes including diminished distress) prior to injury could impact the length can relate to experiencing psychological distress concentration and self-confidence, as well as of their recovery time. For instance, it took 20 including re-injury anxiety (3), depressive increase in distractibility and pain awareness days for 80% of patients with somatic symptoms symptoms (4), and loss of athletic identity (6, 8). In addition, reinjury anxiety may also to recover from a concussion; whereas it took 10

8 AMAA Journal Fall/Winter 2016 Athletes’ willingness to commit to rehabilitation, as well as the value they give to the rehabilitation process, influences their cognitive, emotional, and behavioral reactions to injury rehabilitation

days for 80% of patients without prior physical contexts). They also found that athletes who Podlog and Eklund (7) found that among 12 symptoms (11). This research highlights that positively appraised their injury rehabilitation elite athletes interviewed over a six to eight healthier minds tend to recover quicker from (e.g., viewed their injury as manageable) month period, the injured athletes who adjusted concussions therefore addressing mental health reported feeling happiness and relief, which their goals based on their rate of progress during concerns, such as depressive symptoms, prior to fostered increased adherence to rehabilitation. In the rehabilitation process reported feeling more injury could impact the recovery time required contrast, athletes who negatively appraised their successful during their return to sport compared following a serious injury. Although research has injury rehabilitation (e.g., viewed their injury to the injured athletes who did not adjust their not explicitly examined depressive symptoms as causing stress) reported feeling frustration, goals (7). The majority of successful goal prior to or following injuries commonly which led to hesitancy and cautiousness toward setting interventions included setting goals that experienced by endurance athletes, such as completing exercises in their rehabilitation provide structure, steps, and motivation for pulled muscles, sprains, or shoulder injuries, program. Further, in 2008, Carson and Polman achieving specific milestones in injured athletes’ one could predict that endurance athletes are (13) found that during rehabilitation injured rehabilitation, and customizing the goals to fit also at increased risk for developing mental athletes tended to seek more emotional support the individual’s needs (17). Additionally, some health concerns, such as depressive and anxiety from the staff in charge of rehabilitation as researchers have begun exploring the impact symptoms, following injury especially a career opposed to family. Injured athletes may find of mindfulness, a type of meditation focusing ending injury. that emotional and informational support from on the breath, being in the present moment, athletic trainers, physicians, or professionals and remaining non-judgmental of any thoughts, Impact on Rehabilitation familiar with the rehabilitation process is more or feelings that arise during the course of the Athletes’ willingness to commit to helpful for managing stress associated with their meditation, on helping athletes with pain, rehabilitation, as well as the value they give to injury compared to what is offered by family and stress and anxiety management, and focus the rehabilitation process, influences their significant others (14). (17). Additionally, integrating self-compassion cognitive, emotional, and behavioral reactions exercises holds promise in helping athletes to injury rehabilitation (12). Thus, the way Recommended Psychological address self-critical thoughts, stress and anxiety, athletes perceive their injury rather than the Interventions as well as difficulties with focus and pain which fact that the injury occurred has a critical role Few medical professionals are aware of the tend to arise following injury. in understanding athletes’ emotional responses, psychological interventions which have helped Further, imagery is a psychotherapeutic such as depression, reinjury anxiety, and grief. athletes cope with the mental consequences intervention defined as creating sensory Johnston and Carroll (12) observed that athletes of injury, including setting and adjusting goals rich images within one’s mind (18). Within who reported a high fear of reinjury also had during the rehabilitation process and imagery medical contexts, researchers have conducted certain behavioral responses, including but not paired with diaphragmatic breathing intended to interventions where relaxation imagery (e.g., limited to being hesitant, not giving 100% effort, induce relaxation (15, 16). Goals can be defined imagining a peaceful place) and motivational and being wary of injury-provoking situations as attaining a specific level or proficiency on imagery (e.g., imagining a medical procedure (e.g., during rehabilitation and in sporting a task, usually within a specified time period. continued on page 10 AMAA Journal Fall/Winter 2016 9 The injured athletes who adjusted their goals based on their rate of progress during the rehabilitation process reported feeling more successful during their return to sport compared to the injured athletes who did not adjust their goals.

continued from page 9 following their physical recovery and should the risk? Scand J Med Sci Sports 2006: 16(5):364-375. be encouraged to seek services from sport 11. Ossola A. Healthier minds recover from concussions or treatment being successful) is often paired quicker (April 2016). Retrieved from http://www. psychologists or sport consultants certified popsci.com/people-recover-faster-from-concussions-if- with diaphragmatic breathing to help individuals through the Association of Applied Sport they-were-psychologically-better-beforehand. cope with cancer (19), fibromyalgia (20), and Psychology (AASP). 12. Johnston LH, Carroll D. The context of emotional tension induced headaches (18).Within sport, responses to athletic injury: a qualitative analysis. motivational imagery paired with diaphragmatic J Sport Rehabil 1998; 7:206-220. Shelly Sheinbein is a doctoral intern at 13. Carson F, Polman R. ACL injury rehabilitation: a breathing is frequently used by athletes, coaches, Northwestern University Counseling and psychological case study of a professional rugby union and sport psychologists to enhance skill Psychological Services. She will receive player. J Clin Sport Psychol 2008; 2:71-90. acquisition and recently cognitive specific imagery 14. Yang J, Peek-Asa C, Lowe JB, Heiden E, Foster DT. her PhD in Counseling Psychology with a Social support patterns of collegiate athletes before and (e.g., imagining oneself successfully performing specialization in Sport Psychology from the after injury. J Athl Train 2010; 45(4):372. in game situations and in the situation in which University of North Texas by August 2017. Her 15. Cupal D, Brewer B. Effects of relaxation and guided they had previously been injured) has shown to imagery on knee strength, reinjury anxiety, and pain research focuses on examining the impact following ACL reconstruction. Rehabil Psychol 2001; be effective in reducing injured athletes re-injury of psychological interventions on athletes’ 46(1):28-43. anxiety, experience of pain, and improving speed physical and mental recovery following serious 16. Maddison RR, Prapavessis HH, Clatworthy MM, Hall of physical healing (15, 16). For instance, Evans sport injury. Shelly is a former NCAA Division CC, Foley LL, Harper TT, Brewer BB. Guided imagery to et al. (21) interviewed three rugby players in improve functional outcomes post-anterior cruciate III women’s lacrosse player and has completed ligament repair: randomized-controlled pilot trial. their mid-twenties who had undergone surgery several marathons and speed triathlons. Scand J Med Sci Sports 2012; 22(6):816-821. to repair a sport-related injury (i.e., dislocated 17. Mosewich AD, Crocker P, Kowalski KC. Managing shoulder, fractured fibia and tibia, or torn ACL). injury and other setbacks in sport: experience of (and REFERENCES resources for) high-performance women athletes. Each participated in a minimum of three months 1. Tripp DA, Stanish W, Ebel-Lam A, Brewer BW, Birchard Qualit Res Sport Exerc Hlth 2014; 6(2):182-204. J. Fear of reinjury, negative affect, and catastrophizing of rehabilitation and they completed daily self- predicting return to sport in recreational athletes with 18. Abdoli S, Rahzani K, Safaie M, Sattari A. A randomized reflection diaries that provided information for anterior cruciate ligament injuries at 1 year postsurgery. control trial: the effect of guided imagery with tape Sport Exerc Perform Psychol 2011; 1(S):38-48. and perceived happy memory on chronic tension type the consultations, and practiced cognitive specific headache. Scand J Caring Sci 2012; 26(2):254-261. 2. Bredeweg SW, Klitenberg B, Bessem B, Buist I. imagery over the course of three months. Their Differences in kinetic variables between injured and 19. Liossi C, Hatira P. Clinical hypnosis versus cognitive results indicated that the imagery intervention noninjured novice runners: a prospective cohort study. behavioral training for pain management with pediatric J Sci Med Sport 2013; 16(3):205–210. cancer patients undergoing bone marrow aspirations. was associated with reduced reinjury anxiety, and Int J Clin Exp Hypn 1999; 47:104-116. increased confidence in overall level of fitness and 3. Kvist J, Ek A, Sporrstedt K, Good I. Fear of re-injury: A hindrance for returning to sports after anterior cruciate 20. Menzies V, Taylor AG, Bourguignon C. Effects of in returning to sport (21). ligament reconstruction. Knee Surg Sports Traumatol guided imagery on outcomes of pain, functional Arthrosc 2005; 13:393-397. status, and self-efficacy in persons diagnosed with fibromyalgia.JACM 2006; 12(1), 23-30. Conclusions 4. Mainwaring LM, Bisschop SM, Comper P, Hutchison M, Richards DW. Emotional response to sport concussion 21. Evans L, Hardy L, Fleming S. Intervention strategies For many endurance athletes getting injured compared to ACL injury. Brain Injury 2010; 24(4):589– with injured athletes: an action research study. is a normal part of the sport which may require 597. Sport Psychol 2000; 14(2):188-206. a few weeks of working with a physical therapist 5. Clement D, Arvinen-Barrow M, Fetty T. Psychosocial responses during different phases of sport-injury or at most a short break from participation. rehabilitation: a qualitative study. J Athl Train 2015; However, when the injury is more serious and 50(1):95-104. requires surgery it can quickly become a 6. Tripp DA, Ebel-Lam A, Stanish W, Brewer BW, Birchard J. Fear of reinjury, negative affect, and catastrophizing distressing setback, an event often appraised as predicting return to sport in recreational athletes impeding progress toward desired goals and for with anterior cruciate ligament injuries at one year postsurgery. Rehabil Psychol 2007; 52(1):74-81. some ending their athletic career. Athletes who 7. Podlog L, Eklund RC. High-level athletes’ perceptions have suffered serious injury can likely relate of success in returning to sport following injury. to the psychological consequences discussed Psychol Sport Exerc 2009; 10(5):535-544. in this article and would have benefitted from 8. Poulsen M, Fabrin J, Carstensen JP, Ulnits L, Lausten GS. Reconstruction of anterior cruciate ligament using receiving a psychological intervention, such as bone-patellar tendon bone graft or fascia lata graft. A goal setting, imagery, or mindful self-compassion retrospective study of functional results. Ugeskr Laeger following their injury. Athletes with prior mental 2003; 165(7):682-5. 9. Walker N, Thatcher J, Lavallee D. A preliminary health concerns, as well as athletes requiring development of the re-injury anxiety inventory (RIAI). surgery and a greater absence from participation Phys Ther Sport 2010; 11(1):23-29. in sport or physical activity are at greater risk for 10. Thing LF. The resumption of non-professional female players’ sports career after anterior cruciate ligament experiencing lingering mental health concerns injury. The female player’s dilemma: is she willing to run

10 AMAA Journal Fall/Winter 2016 paper in which 20 heel-toe runners were instructed Should You Change an Athlete’s Natural to run using the Pose technique (4). Biomechanical Running Form? analysis revealed that compared to conventional heel-toe running, Pose running resulted in shorter By Thomas C. Michaud, DC stride lengths and smaller vertical oscillations of the pelvis. Just as Romanov suggested, Pose runners reduced the magnitude of the initial impact force and also reduced stress on the knee. The only downside was that the Pose runners had increased stress at the ankle. The results of this study were similar to a According to many running experts, making a techniques strongly discourage making initial more recent study comparing impact forces and few small changes in running form can improve ground contact with your heel. Chi runners are movement differences between conventional speed, efficiency, and reduce injury rates. Alberto taught to strike the ground with the midfoot; while heel-strike runners and runners experienced Salazar is famous for changing everything from the Pose runners make contact a little farther forward in Chi running (5). As with the Pose study, the tilt of a runner’s pelvis to the position of his or her on the ball of the foot. Another key concept in Chi Chi runners had significant reductions in initial thumbs (1). From a biomechanical perspective, and Pose Running is that you must strike the ground impact force and knee stress, but had to absorb it makes sense that nearly every runner has some with your lead foot directly beneath your pelvis. Chi more force with the ankle. Regardless of the slight imperfection in form that can detract from and Pose advocates state that because this contact added stress on the ankle, these two studies optimal performance. Think of the auto industry point shortens your stride, when you want to run seem to confirm that Chi and Pose running do putting cars in wind tunnels and blowing streams faster, you must increase your step frequency (i.e., what they say: they reduce initial impact force of smoke over the cars’ exteriors to identify design cadence). Overstriding is to be avoided at all costs. while also lessening stress on the knee. problems that could result in reduced gas mileage. Both Chi and Pose say the ideal running cadence is A problem with both of these studies is that As related to running, identifying and correcting approximately 180 steps per minute. the reduced impact forces and lessened knee slight biomechanical glitches should theoretically With more than 50% of runners getting injured strain associated with Chi and Pose running improve efficiency and increase speed. each year, the notion that a recreational runner most likely had nothing to do with the changes in could reduce the risk of injury while becoming running form and everything to do with the fact Two Popular Running Techniques faster and more efficient is definitely appealing. that the Chi and Pose runners ran with shorter Although there are dozens of running clinics The question is, do claims of improved efficiency stride lengths. If the heel-strike runners would out there, the most popular techniques for teaching and reduced injury rates have merit? In the past few have shortened their strides the same amount as running form are Chi Running (2) and Pose years, several studies have evaluated Pose and Chi the Chi and Pose runners, they more than likely Running (3). The ideal running form that Chi and Running. In 2004, the prestigious journal Medicine would have had the same reduction in impact Pose Running recommend are very similar. Both and Science in Sports and Exercise published a forces, even if they were running with the worst running form possible.

Impact Forces and Ground Contact The reason stride length is so important is because impact forces are stride length dependent: the shorter you make your stride, the lower the initial impact force will be. In fact, researchers from the University of Wisconsin (6) prove that regardless of running form, runners who decrease their stride length while increasing their cadence can maintain the same running speed while reducing impact forces by as much as 20%. Rather than having a patient spend years trying to master a specific running form, these authors prove that impact forces can be dramatically reduced with a few simple changes in stride length and cadence. Another common misconception regarding running form is that it is always better to make initial ground contact with the mid or forefoot. According to many running authorities, striking the ground with your heel should be avoided Fig. 1. By leaning slightly forward at the hips (arrows A and B), runners use at all costs. Contrary to popular belief, studies their upper hamstrings (C and D) to absorb force that would normally be involving thousands of athletes show there is no absorbed by the knee. Some great research proves that the world’s best runners difference in injury rates between runners making make initial ground contact with their upper bodies tilted slightly forward, while less initial contact with the heel and those striking with efficient runners contact the ground with their spines almost vertical (12). a more forward contact (7). Furthermore, the vast majority of recreational runners are more continued on page 12 AMAA Journal Fall/Winter 2016 11 continued from page 11

Fig. 2. Joint and muscle interactions present while run- absorption because it prevents the opposite hip from lowering (G). ning. Initial contact (A) can be made with the heel, midfoot, or The best runners maintain their pelvis in an almost horizontal line, forefoot. The upside of a heel contact is that it reduces stress on with their knee pointing straight forward. In contrast, runners with the Achilles tendon and arch and allows the foot to smoothly roll poor form allow their opposite hip to drop (H) and their knee forward (arrow B). The downside is that a heel contact increases to twist in (I). Excessive inward rotation of the knee is one of the force absorbed by the knee. Forefoot contact points (C) allow the worst errors in running form and should be corrected with hip gastroc muscle to absorb force, reducing stress absorbed by the strengthening exercises and gait retraining (i.e., treadmill running knee by as much as 50%. The downside of the forefoot contact is in front of a mirror while deliberately keeping the knees moving in that it can overload the Achilles tendon and the metatarsals. Also, a straight line). because the initial point of contact acts as a pivot during ground Though rarely discussed, backward rotation of the hip at impact contact (arrow), forefoot contact points cause the heel to initially (J) is the body’s most important shock absorber (14). Excessively drop down and back (D), temporarily acting as a brake. Although stiff and/or weak hips can lead to injuries by limiting the ability of not illustrated, making contact along the outside of the entire foot the large hip muscles to absorb shock. Because of this, chiropractic (i.e., a midfoot contact point), is often considered the perfect treatments or other effective methods to enhance hip flexibility, contact point, representing a blend between forefoot and rearfoot especially in the posterior capsule, are important for improving contact points. This statement is controversial since 75% elite run- shock absorption. Another common running form problem associ- ners strike the ground along the outside of their heels (13). ated with tight hips is the crossover running gait. In this running Once past the ankle, impact forces travel at about 200 mph into form, the athlete allows his or her feet to crossover a midline while the knee. In addition to allowing the quad to absorb force, bending running. This style of running increases the risk of lower leg stress the knee (E) prevents the hip and pelvis from moving up-and- fractures and tendon injuries. Again, improving hip flexibility and down too much (F), which is important for injury prevention and strength is the key to correcting this running flaw. efficiency. The gluteus medius muscle is also important for shock

12 AMAA Journal Fall/Winter 2016 excessive frontal plane motion at the pelvis, the runner is almost always the best judge at choosing If your goal is to have a running patient become fast the running form that is right for them. and efficient, be cautious about making significant Dr. Thomas Michaud specializes in biome- changes in form because runners intuitively pick the chanical and gait disorders and is the author running style that works best for them. of numerous book chapters and journal articles on a variety of subjects ranging from biomechanics of the first metatarsophalan- geal joint and shoulder, to the pathomechan- efficient when striking the ground heel-first. In a better approach would be to incorporate a slight ics and management of vertebral artery dis- recent study evaluating efficiency while running forward lean at the hips. section. He is also the author of the textbook at different speeds, researchers from Spain prove Keep in mind that while making subtle Foot Orthoses and Other Forms of Conservative that compared to mid and forefoot strikers, changes in running form can reduce the potential Foot Care, which has been translated into slower recreational runners are almost 10% more for injury, the majority of research suggests that four languages and used in physical therapy, efficient when striking the ground with their heels making even a slight change in the way you run chiropractic, pedorthic, and podiatry schools (8). The benefits associated with heel striking will reduce overall efficiency. Remember, although around the world. continue until runners reach the 6:25 minute per runners trained in the Pose style of running have REFERENCES mile pace, after which heel and midfoot contact significant reductions in impact forces traveling 1. Kahn J. The Perfect Stride: Can Alberto Salazar points are equally efficient. The reduced efficiency through the knee, they become significantly less straighten out American distance running? The New associated with mid and forefoot contact points efficient (9). According to exercise physiologist Yorker. November 8, 2010. while running at slow speeds explains why Pose Tim Anderson (11), runners are able to critically 2. Dreyer D. (2004) Chi Running: A Revolutionary Approach to Effortless, Injury-Free Running. New York, Runners, despite having reduced impact forces, evaluate the metabolic cost of every step while NY: Simon & Schuster. are considerably less efficient than conventional running to develop a unique running style that is 3. Romanov N. (2002) Pose Method of Running. Coral heel-strike runners (9). most efficient for them. Gables, FL: Pose Tech Press. . Studies comparing impact forces associated Even though changing running form almost 4. Regan A, Noakes T, Azevedo L, et al. Reduced eccentric loading of the knee with Pose Running with different contact points consistently show always results in reduced efficiency, there are method. Med Sci Sports Exerc 2004; 2:272-277. that the same force is absorbed by your body certain movement patterns present in runners 5. Goss D, Gross M. A comparison of negative joint work whether you strike with your heel or forefoot, that greatly increase the risk of injury and should and vertical ground reaction force loading rates in Chi runners and rearfoot-striking runners. J Orthop Sports the force is just absorbed by different joints. therefore be modified. Figure 2 reviews the Phys Ther 2013; 10:685-692. Runners who strike the ground with the forefoot basics of running form and describes common 6. Heiderscheit B, Chumanov E, Michalski M, et al. absorb more force with their arches and calves, flaws that should be corrected. Excessive inward Effects of step rate manipulation on joint mechanics while runners making initial contact with the rotation of the hip during stance phase is during running. Med Sci Sports Exerc 2011; 43:296-302. 7. Kleindienst F, Campe S, Graf E, et al. Differences heel absorb more force with their knees. Force especially problematic because it often results in between fore- and rearfoot strike running patterns absorption at different locations explains the chronic retropatellar pain. based on kinetics and kinematics. XXV ISBS Symposium higher prevalence of Achilles and plantar fascial 2007, Ouro Preto, Brazil. 8. Ogueta-Alday A, Rodriguez-Marroyo J, Garcia-Lopez injuries in mid and forefoot strikers and the Conclusion J. Rearfoot striking runners are more economical than higher prevalence of knee pain in heel strikers. In summary, the research on running form midfoot strikers. Med Sci Sports Exerc 2014; 3:580-585. This is the biomechanical version of “nobody consistently shows that if your goal is to have 9. Dallam G, Wilbur R, Jadels K, et al. Effect of global alteration of running technique on kinematics and rides for free.” If you’re treating a fast runner who a running patient become fast and efficient, economy. J Sport Sci 2005; 7:757-764. has a tendency for knee pain, you might want to be cautious about making significant changes 10. Hsiang-Ling T, Powers C. Sagittal plane trunk posture consider gradually transitioning the athlete to run in form because runners intuitively pick the influences patellofemoral joint stress during running. with a more forward contact. Conversely, runners running style that works best for them. The most J Orthop Sports Phys Ther 2014; 10:785-792. plagued by chronic Achilles injuries should be effective way for advanced runners to improve 11. Anderson T. Biomechanics and running economy. Sports Med 1996; 22:76-89. encouraged to run with a heel-first strike pattern form and efficiency is to perform high-intensity 12. Williams K, Cavanagh P. Relationship between in order to reduce the potential for reinjury. plyometric drills designed to increase tendon distance running mechanics, running economy, and An alternate option for a runner with knee resiliency. Improvements in running form will performance J Appl Physiol 1987; 63:1236-1246. pain is that rather than striking the ground naturally follow. Conversely, if your goal is to have 13. Hesegawa H, Yamauchi T, Kraemer W. Foot strike patterns of runners at the 15-km point during an elite along the midfoot, the athlete should lean a running patient avoid injury, the easiest way to level half marathon. J Strength Cond 2007; 21:888-893. slightly forward at the hips during stance phase. do this is to reduce impact forces by shortening 14. Pandy M, Berme N. Quantitative assessment of Researchers from the University of Southern the overall stride length while increasing cadence. gait determinants during single stance via a three- dimensional model-Part 1. Normal gait. J Biomech 1989; California (10) prove that a slight forward Because the best predictor of future injury is prior 22:717- 724. lean while running transfers forces that would injury, you should encourage a running style that normally be absorbed by the knee into the upper accommodates prior injuries; e.g., runners with a Reprinted with permission from Dynamic Chiropractic hamstrings and hip with no added force being tendency for knee pain should consider making 2015; (33)13. absorbed by the foot or ankle (Fig. 1). The initial ground contact on their midfoot, while authors point out that because distance runners runners with a history of Achilles injuries should rarely hurt their upper hamstrings, rather strike the ground heel first. The bottom line is than increasing the risk of an Achilles injury that excluding a few obvious examples, such by transitioning to a midfoot contact point, a as excessive inward rotation of the knee and/or

AMAA Journal Fall/Winter 2016 13 Runners of Yesteryear

By Paul J. Kiell, MD

Many of us may look back at our running body well. His legs were severely burned in a “careers” and think about how training methods schoolhouse fire when he was eight or nine years have changed since we first laced up our running old. Over a two-year period he learned to walk shoes. For some, we may even wish we could go again and eventually was able to run. Lacking a back in time to correct a few of our bad training walker, he rehabilitated by grabbing a mule’s tail habits. Perhaps we could have avoided some and going along for the ride, or taking a swing of our overuse injuries, or even achieved that on a rusty gate. elusive PR. Because of Cunningham’s otherwise Following this notion, I thought it would be debilitating burn injuries, his warm-up was fascinating to go farther back to look at training unique and bears lengthy description. In a 1986 methods from athletes who competed in the recorded telephone interview with him, I asked first half of the 1900s. Like us, they were pure “You had to take an unusually long warm-up amateurs holding daytime jobs. For instance, didn’t you?” He responded, “Yes, I did because in the epic 1936 Berlin Olympiad 1500m run, I had several things that were against me. If I Dr. Jack Lovelock was a medical student and didn’t warm my legs up properly, the circulation Glenn Cunningham was at NYU studying for his not being good, they would naturally tie up. Then doctorate in biological sciences and physical I had this neck injury, which would tie up my education. shoulders, and spread all over me if I didn’t get it Running during his Today, yesteryear’s runners’ methods of loosened up real good.” one-hour lunch period, training may seem out-of-date, as only a footnote His Kansas University coach Bill Hargiss also of running’s evolutionary history. But much still described his warm-up: “In all Glenn’s racing in Bannister compressed his applies. They were efficient and economical in the years that followed, he held to the practice running workouts into time. Much can be learned and/or extrapolated of the tremendous warm-up. He set the pattern, from their training regimens. In many ways they I think. It was a matter of the adjustment of the sessions of 48 minutes were analogous to all of us who have, or have body, of the heart and lungs, and the metabolism per day, where he focused had, “daytime jobs,” with running being both a of the muscles. The long warm-up eliminated the upon intense interval diversion and a much-valued hobby. phenomenon of the second wind. This second The runners discussed here, at one time wind, so-called, is just a phenomenon of the training to build a or another, appeared at our AMAA sports body catching up, of eliminating carbon dioxide sustained finishing kick. medicine symposiums. The main focus will be through perspiration, and through the lungs, to Glenn Cunningham (1909-1988) with quotes make ready for more oxygen. In other words, if His methods, born out of from my book American Miler about this you start out in a hard race without warming up . necessity, were in stark heroic figure. Cunningham spoke at our 1987 . . you’re just not going to run very well because post-Boston Marathon banquet. I will also of this business of the body adjusting to it.” contrast to the usual discuss Abel Kiviat (1990 NYC Marathon AMAA Sports writer George Trevor described training undertaken by symposium speaker), Roger Bannister (1982 Cunningham’s warm-up as “There’s a purpose mile runners at the time. Boston Marathon symposium speaker), and Dr. behind his eccentric going-on. He tosses his Jack Lovelock (1910–1949) who, in an epic head to loosen up the muscles of his neck; he run at the 1936 Olympic 1500m, edged Glenn snorts to clear nasal passages which are too Cunningham. small for a runner; he prances around the track Abel Kiviat placed second in the 1500m race at before a race to warm up legs which are covered the 1912 Stockholm Olympiad. Nearing age 100, with scar tissue as the result of burns suffered in appearing at our 1990 New York City AMAA sports a schoolhouse fire; he waits until all rivals are medicine symposium, feisty and garrulous, he stripped for action before removing his sweat regaled us with stories of rooming with the fabled suit in order to keep those scorched legs from yet unruly Jim Thorpe. He died less than year later; being chilled.” (Author’s note: This lengthy quoted in his obituary, “Today, you hear of high description of Cunningham’s unique warm- school kids running 50 to 60 miles a week. I never up has application today. Not only is warm-up ran five miles in a week.” important, but also it is an individual matter. Such was not unusual and not that different Furthermore, the explanation of the “second from Glenn Cunningham’s regimen. But wind” is applicable although present technical Cunningham was a thinker and knew his own explanations may differ.) 14 AMAA Journal Fall/Winter 2016 Tuesday, I would take my hard workout, but after the warm-up I would never run over three quarters of a mile. I would only do that usually for short distances, like two 660s or three single quarters. Sometimes I’d just sprint 220s and walk 220s and sprint 220s, or maybe sprint a straightway and walk the turns.” Bill Hargiss, after describing Cunningham’s weight lifting and overall body building regimen–something discouraged at the time by most coaches–added “And, by golly, there’s another thing coaches turned thumbs down on in those days. That’s swimming. Yet Jack Lovelock trained more in the swimming pool than he did on the track.” This is reminiscent of something Dr. George Sheehan, one of the leading college milers of Cunningham’s time, advised about injury: “Go to the pool.” That certainly made sense. Intense Abiel Kiviat (left), age 98, and Dr. Paul Kiell at AMAA’s Sports Medicine training often brings with it injury or at least Symposium at the NYC Marathon (1990). near injury. Legwork in the pool will hasten injury healing. Hopefully this trip down training’s memory Coach Bill Hargiss described Cunningham’s world’s record: Jim Ryun, Wes Santee and myself lane has been helpful both historically and pre-race meal and also some of his off-the- . . . I couldn’t believe that track and those shoes. pragmatically. Remember too, for those of us who track attitudes: “Off the track Glenn is a most The shoes were so light. It was like they were are older—personal bests and running mileage religious trainer. There is no diet prescribed for filled with helium. I couldn’t keep them on the of yesterday glimmer and fade with father time’s him. He eats plain, simple food and not in large track. It was unbelievable the difference in what relentless rule. I paraphrase Joe Henderson’s amounts. He eats very slowly. Drinks only milk I had to contend with when I was competing.” words about performance and time: “Instead of and water, never coffee or tea; has never had a Dr. Roger Bannister, another guy with a concentrating on our times being good, let’s just drink of alcoholic liquor of any kind; does not day job, practiced similar training regimens. focus on having a good time.” drink any fountain soft drinks; has never used Bannister’s workouts, particularly when tobacco in any form. Fruit and vegetables play training to break the four-minute mile, were (Author’s note: If you search the Internet on a prominent role in his diet, but he eats meat, similar to Cunningham’s. Bannister did repeats Jack Lovelock, you will find the epic 1936 preferably beef, once or twice a day. About three of the three-quarter mile hoping to break three- Olympic 1500m newsreel race. Furthermore, the hours before he runs he eats the biggest meal minute repeats. narrating voice is that of the Harold Abrahams of the week, including a thick broiled steak. He Running during his one-hour lunch period, from Chariots of Fire fame.) sleeps regularly and aims to get at least eight Bannister compressed his running workouts hours sleep each night.” into sessions of 48 minutes per day, where he Psychiatrist Dr. Paul Kiell, a former I am tempted to point out how much track focused upon intense interval training to build a marathoner and now active masters times have changed. The myth of the invincibility sustained finishing kick. His methods, born out swimmer, has written extensively on both of the four-minute mile has been shattered. But of necessity, were in stark contrast to the usual topics. Among his books are Exercise and the can it all be attributed to training methods? In the training undertaken by mile runners at the time Mind: The Possibilities for Mind-Body-Spirit 1986 phone interview, Cunningham talked about (late 40s to mid-50s), where weekly totals of 70 Unity (2010) and American Miler: The Life and an invitational run in 1981with Ryun and Santee miles (115 km) or more were common. Times of Glenn Cunningham (2006). at the University of Kansas Relays: “There’s one Cunningham’s workouts were similar to big thing you have to consider when you compare Bannister’s. He stated, “I was never able to do yesterday’s performance with that of today. a lot of training as far as practice running was We have improved our equipment. The shoes concerned. Most of today’s athletes run from now are just designed so well. The University 75 to 150 miles a week. I never ran over five of Kansas, I believe is the only University in the to seven miles and only went on the track three country that has three milers that have held the days a week: Monday, Tuesday, and Wednesday. AMAA Journal Fall/Winter 2016 15 journey of swimming history and legend through BOOK REVIEWS and including modern times, pop culture heroes, poets, movies, and famous personalities Ed. Note: Drs. Doug Munch and Paul Kiell are both refugees from the running world. from Ben Franklin to Barack Obama who helped Nevertheless they are both now comfortably ensconced in the swimming world. make swimming the major sporting event and Paul was a competitive swimmer turned marathon runner. He completed 17 Boston recreational passion we recognize it to be today. Marathons and many other endurance events. Sadly, he suffered repeated episodes of DVTs in his Contemporary competitive swimming left lower extremity that forced him to give up running. He reports, “Luckily I had swimming. demands four strokes: free style, back stroke, After a 40-year absence I was a swimmer again.” breast stroke, and butterfly. These strokes are the Doug was an elite quarter-miler and high jumper until a leg injury forced him to the sidelines. common currency for modern swimmers, both A natural athlete, midway through his athletic journey he turned to swimming and cycling for for training and competition. Not surprisingly, both continued fitness and occasional competition. this was not always the case. Imagine for a The physical and mental benefits run parallel in these two sports. Unique to swimming is moment the development of high jumping style that it can be relatively injury-free. The reviews presented here will elaborate further on the good in track and field. In many of our lifetimes we things about swimming. have seen the dramatic performance changes resulting, in part, from the evolution in technique for many of us is to find other activities that from scissors, western roll, straddle, and provide the same benefits of running, without the currently, the Fosbury Flop. Ms. Sherr takes us pounding and recurrent injuries. Two activities through a similar, albeit more complex, amusing come to mind: cycling and swimming. They both and fascinating evolution of swim strokes and provide excellent alternatives to our favorite apparatus for enjoyment and eventually to top fitness regimen, without the pounding and offer level modern competition. Her vignettes cover the possibility of entering triathlons as a relay. the waterfront of a lifetime of observations from For Lynn Sherr, however, swimming was not breath control and swim workouts, to training an alternative or substitute for running. It was an to swim fast. Her descriptions are rendered enjoyable and absorbing part of her life since with alacrity, without creating boredom or the a toddler. But this book is not really about her dryness of a swimming magazine or “how-to-do- personal journey from a youthful love of the it” book. I found this book is filled with “I didn’t water to her more recent objective of swimming know that” factoids that often resolve into “isn’t the Hellespont channel in Greece. Her journey that something” moments. to swimming this dangerous straight between The late Dr. Oliver Sachs, renowned Europe and Asia is more like an intermittent neurologist, author, and former weightlifter theme that resurfaces throughout the pages. turned swimmer talked about the “essential Instead, Ms. Sherr takes us on a seamless rightness of swimming” and that learning to Swim: Why we Love the multifaceted voyage of swimming lore and breathe bilaterally as simply additional further Water history without becoming an obvious apologist proof about the plasticity of the brain, even older for the sport. brains. An acquaintance once told me that the By Lynn Sherr Most of us never think about when humans repetition and focused concentration required in Paperback, 232 pp, PublicAffairs, started to swim. Was it a natural part of our swimming is also a meditation. While Sherr offers Perseus Books Group, 2012 genetic makeup originating when fish evolved examples of swimming’s “essential rightness,” to amphibious creatures and then to land- the real essence of this book is passion. To Reviewed by Douglas F. Munch, PhD based animals? After all, many of us may have paraphrase Lynn, swimming is an adventure that learned from embryology that in the 1870s, can await each of us, whether it is in a pool, swim When a broadcast journalist and writer dive Ernst Haeckel first formulated the concept that meet, or open water event. into a topic that has engrossed her for years, “ontogeny recapitulates phylogeny,” a catchy If you swim or are considering swimming things are certain to get interesting. In fact, not phrase although largely defunct in its original as a supplement or alternative to your current just exciting but surprisingly informative as well, meaning today. But Haeckel wasn’t the first to training, Swim: Why we Love the Water is an leaving few stones unturned. And by the end, she believe that there was truth in some form of enjoyable and informative read. reveals the emotional depth that swimming has recapitulation theory. That honor goes back Did Lynn complete the challenging and played in her life and can play in ours. to the ancient Egyptians in about 640 BCE. potentially dangerous Hellespont swim? Well, First, an aside. Why would one review a book Swimming was so important in ancient Egypt that that’s part of the story and the journey. You’ll just on swimming in a journal that has traditionally swimmers are depicted in hieroglyphics from have to read the book to find out. focused on runner’s issues? To me, the answer ancient Egyptian tombs 1000s of years ago. In to this question is pretty straight forward. I have 360 BCE, an ancient Greek proverb declared Dr. Douglas Munch is a medical consultant met any number of AMAA members who were that ignorance in a man is defined as one who and longtime competitive athlete in track dedicated runners for years, myself included. can neither read nor swim. Centuries later, Lord and swimming. He received his doctorate Due to years of pounding on the track or roads, Byron, swimming for glory, emulated Leander’s in medicine and biomedical engineering many of us have sustained injuries that preclude legendary swims for romance to visit his beloved from the Johns Hopkins University School of continued running, although fitness (and maybe Hero, swam the Hellespont in 1810 and then Medicine in Baltimore, Maryland. competition) have been a part of our lifestyle set his achievement to poetry. Sherr doesn’t that we are disinclined to give up. The solution stop there. She walks us through an enchanting 16 AMAA Journal Fall/Winter 2016 requires a strong moral principle to prevent me everything she’d ever accomplished. You from deliberately stepping into the street, and could easily say, “She had heart.” Literally and methodically knocking people’s hats off––then, figuratively her heart was her strength. Ironically, I account it high time to get to the sea as soon as she would become a victim of “Broken Heart I can. This is my substitute for pistol and ball.” Syndrome.” What then is such an entity? Learning Blue Mind tells of, and scientifically about this condition should be of utmost interest validates with cutting-edge neuroscience, the to everyone, especially practitioners of maladies benefits of exercise per-se, particularly of water, of the heart. as regulators of the brain neurohormones We are all acquainted to phrases in literature (endorphins, dopamine, serotonin, etc.), and everyday communication like “it broke my explaining why we are attracted to the streams, heart.” Such phrases now have gained scientific the lakes, the rivers, the oceans, and to top validity. How did this condition arise and it off, even to the color blue itself. The author specifically how did it hatch in Lynne Cox? successfully shows how, through water, we can `Cox was lovingly taking care of her elderly improve performance, relieve stress and anxiety, parents. Then, in a short span of time, both and increase overall well-being. died. Their passing was followed by the death of her beloved Labrador Retriever. She was, Blue Mind: The figuratively, now living in a broken heart state. Surprising Science That Literally too. Soon she was beset with bouts of atrial fibrillation, pulmonary edema with fatigue, Shows How Being Near, and breathlessness, all validated by an ejection In, On, or Under Water fraction of 15% (normal 15-70%), the product of enlarged dilated ventricles. Even cardiac Can Make You Happier, transplant was considered. Healthier, More The title of the book tells of the times she would actually move her hands and arms in a Connected, and Better filled sink, “baby steps” in her determination to at What You Do rehabilitate. Inspiring is her path to total recovery, By Wallace J. Nichols, PhD motored by excellent medical care, friendships, Paperback, 368 pp, Little, Brown and and the elements of her character that made her Company, 2014 a championship athlete. Reviewed by Paul J. Kiell, MD Psychiatrist Dr. Paul Kiell, a former marathoner and active masters swimmer, has written I’m always impressed at the prescience of extensively on both topics. Among his books authors and poets where they describe the more are Exercise and the Mind: The Possibilities for transcendent benefits of aerobic exercise. For Swimming in the Sink: Mind-Body-Spirit Unity (2010) and American example, the old Roman dictum Mens sana in An Episode of the Heart Miler: The Life and Times of Glenn Cunningham corpore sano (You should pray for a healthy (2006). mind in a healthy body) or the last lines of By Lynne Cox Dryden’s 18th century poem: The wise, for cure, Hardcover, 240 pp, Knopf Doubleday, on exercise depend; God never made his work 2016 for man to mend. In Blue Mind, proclaiming the power of Reviewed by Paul J. Kiell, MD water to heal his mental state, just note this quote originally from Herman Melville’s Moby-Dick, Lynne Cox is an elite athlete who has made spoken by the protagonist, Ishmael: her mark in frigid open water swims. She first “Some years ago––never mind how long swam the English Channel at age 15 and was precisely––having little or no money in my purse, the first woman to swim across Cook Strait (18 and nothing to interest me on shore, I thought I miles). Of particular note, she was first to swim would sail about a little and see the watery part off Antarctica in 32-degree Fahrenheit water, of the world. It is a way I have of driving off the without the benefit of a wetsuit, for 25 minutes. spleen and regulating the circulation. Whenever Swimming in the Sink reading begins when I find myself growing grim about the mouth; she is studied at a laboratory at the University of whenever it is a damp, drizzly November in my London. Her extraordinary human capabilities, soul; whenever I find myself involuntarily pausing studied scientifically in ice-cold water, would before coffin warehouses, and bringing up the pave the way for new medical and life-saving rear of every funeral I meet; and especially when practices. my hypos get such an upper hand of me, that it As an athlete, Cox had put her heart into

AMAA Journal Fall/Winter 2016 17 academically and Mark socially: “His focus was Mark Lavallee, MD, school and mine was wanting to meet people,” CSCS, FACSM Mark says. And so Mark tutored Bret. “I was envious of his body, and he was envious of my Overcoming Early Obstacles brain. It was sort of that Gift of the Magi thing,” and Paying It Forward he explains, referring to the classic O. Henry story about the poor couple who perform mutual acts of By Jeff Venables generosity at Christmastime. The classmates eventually became roommates. Ehlers-Danlos Syndrome, or EDS, is a rare Mark says, “I helped him study and Bret’s grades connective tissue disorder characterized by double- went up. And one day he says, ‘Have you ever jointedness, frequent joint dislocations, elastic thought of exercising?’” After explaining that all skin that bruises and tears easily, poor wound physical activity had been contraindicated by a healing, and some life-threatening complications world-renowned genetics doctor, Bret simply such as risk of blood vessel rupture or even aortic asked, “How’s that going for you?” The questioned dissection. It’s thought that EDS appears in about altered Mark’s life journey forever. “I realized it one in every 5,000 live births globally. wasn’t going well,” he says. Traditionally, EDS has severely limited the Soon after this epiphanic moment, and with mobility and activity level of people with this Bret as his personal trainer, Mark tenuously began chronic and painful illness, with bracing and to exercise. When he started, he could not do a corrective surgery often the first lines of defense. single pull-up, nor one push-up. He couldn’t do Physical therapy has today gained much ground more than five sit-ups, and attempting to bench as a supportive treatment, but this was not really press 55 lbs “buried” him. He was 20 years old. the case when AMAA member Mark Lavallee, MD, “I couldn’t even hold onto the pullup bar for was a child in Maryland struggling with this poorly 30 seconds. But he pushed me. Then I could hold understood condition. But to say that all this on for 45. Then it was a minute. Then I could dramatically changed over the course of Mark’s almost bend my elbows. It took me three months remarkable life is an understatement. to do one pull-up,” he says. But he stuck with it. Mark describes the visible effects of EDS by Lavallee went down from 220 lbs to 155 lbs in saying, “I have lots of scars. I pretty much look one year. In that same amount of time his bench like I’ve stepped on a landmine or been burned weight increased from 55 lbs to 135 lbs. Most pretty badly.” His childhood was riddled with joint At the Colorado Springs U.S. Olympic Train- impressively, his shoulder dislocations stopped. dislocations and continuous trips to the doctor. “I ing Center in 1997, Mark demonstrates that an And what about that proscription on overhead Ehlers-Danlos Syndrome sufferer can, indeed, be spent a pretty good portion of my young life getting a weightlifter. movements? Never mind reaching for coffee cups, put back together like Humpty Dumpty,” he says. Mark was now military pressing 135 lbs. He wrote as the first president of the Human Genome to Dr. McKusick, still at Hopkins, with whom he’d Early destiny with medicine Organization. McKusick’s interest in connective had no contact since fifth grade. He even included Also prone to many slicing wounds and tissue disorders led him to become one of the photos of himself performing the military press, abrasions, before finishing boyhood Mark already world’s leading experts on Marfan syndrome, as well as a tongue-in-cheek picture atop a horse. had received thousands of stitches. His fragile whose effects can be similar to EDS, including The doctor told him, “I’m glad you’re ok, and I’m skin led to the unusual effect that his very first double-jointedness, aortic weakening, and other glad I was wrong.” That scientific humility meant experiences of a doctor were of a plastic surgeon. heart problems. a great deal, emboldening Lavallee to crack on. “I And he understandably came to admire doctors Dr. McKusick’s recommendation to Mark? thought,” he fondly recalls, “I’m onto something.” early on in life for their skillful and regular repair No sports—indeed, no overhead movements at work on his broken frame. all. While Mark and his family acknowledged that A hobby? To put this into perspective, Mark suffered 23 the leading expert had been unequivocal in his Today, Dr. Lavallee is a family and sports left or right shoulder dislocations before age 20. assessment, at the same time he wondered, “How medicine doctor and fellowship director (as He lost count of ankle and kneecap dislocations; am I going to put clothes on? How will I get dishes well as a U.S. Olympic team physician), but his finger joints would routinely dislocate out of the cupboard?” several years ago while practicing in South Bend, “multiple times a day.” Indiana, word got out that he also treats EDS By fifth grade Mark knew he wanted a career “How’s that going for you?” patients. And so he uses what he has learned in medicine. Around this time Mark met the By the time Mark was a sophomore at Penn about his own body, as well as about genetics and internationally renowned doctor and professor State, he was overweight at 5’ 7” and over 220 sports medicine, to help people who sometimes of medical genetics Victor McKusick, MD, at the lbs. Understandably, “I felt pretty poor about my even fly in from other countries to be treated Johns Hopkins University School of Medicine. Dr. self-image,” he recalls. Yet as a chance encounter for connective tissue diseases. He calls this his McKusick died in 2008, after a long career that with a classmate began to grow into a friendship, “hobby,” explaining that he never advertised his awarded him what is considered the Nobel Prize something was about to occur that would services in this subspecialty, but there are so few of Japan: the Japan Prize in Medical Genomics fundamentally change his life. physicians who treat EDS that he is known for this and Genetics. He is often described as “the father “I met this guy, Bret, in sophomore year, in places as far away as Canada and Mexico. of modern human medical genetics,” and served who sat next to me in organic chemistry. He was a bodybuilder.” Bret wanted to improve continued on page 19 18 AMAA Journal Fall/Winter 2016 continued from page 18 sucks, but my muscles are ok,” he says. This principle of building up muscle to stabilize In South Bend, he served for 15 years as the the joints is familiar to any runner seeking to stave director of Sports Medicine at Memorial Hospital, off knee problems into and well beyond middle as well as co-director of the South Bend Notre age. But back when he was 20, this concept was a Dame Sports Medicine Fellowship and medical revelation to Mark and he feels incredibly grateful director of the Health and Lifestyle Center, a for Bret’s encouragement and motivation in those medically-based, clinically integrated fitness crucial weightlifting years. Fittingly, Mark has been center, health museum, and clinical space. the IWF medical director for the World Masters Three years ago he moved to York, Weightlifting Championships since 1999, as well as Pennsylvania, and started his clinical practice of for the World Masters Games over a dozen times, sports medicine, family medicine, and an EDS and a team physician for USA Weightlifting for nearly treatment program there as well. He sees these two decades, including serving as chairman for the types of patients only “one half day a week,” but USAW Sports Medicine Committee since 2008. the work is clearly important to him; having come Nowadays, Mark still strength trains a few so far in managing his own condition, Mark is times a week, but has shifted more to distance giving back. swimming, light jogging, and training on an His main roles in York are at Wellspan/York ergometer as his main forms of fitness. He also Hospital where he serves as program director stays active working on his old Willys trucks, as of the York Hospital Sports Medicine Fellowship well as scouting and hiking with his wife, Tara, and and associate director of the Family Medicine Bronze medalist Sarah Robles and Mark at the their two teenage sons. Rio 2016 Olympics. Sarah was the first American Residency program. He is a clinical associate Training for quality of life is more important to win a weightlifting medal since 2000. professor in the Department of Family and to him than competing, and he equally cares for Community Medicine at the Penn State University patients seeking to improve either. As much as he College of Medicine. is proud to serve elite athletes, including several Medical technology changes rapidly, but year. He feels that AMAA’s annual sports medicine U.S. Olympic Trial and Pan-American teams, “It’s Mark never loses sight of what remains of utmost symposium, under the fastidious tutelage of about that 94-year-old woman I saw yesterday with importance in the role of a physician: the patients. Meeting Coordinator Barbara Baldwin, MPH and bone-on-bone arthritis, and all she wants to do is “When it comes down to it, it’s about that human Meeting Chairperson COL Francis O’Connor, MD, just walk, clean her house, and spend time with bond between patient and physician. It’s been a is world-class. “They get great speakers and look her 95-year-old husband,” he says. cool journey,” he says. at intriguing topics. The caliber of that conference He adds that the patient he’d seen just before is extraordinary,” he says. that was a professional runner who is trying to best Shaped—not defined—by EDS But it is the race itself that Dr. Lavallee finds her 3:02 Boston time where he used ultrasound- At age 48 Lavallee is 160 lbs now. He still truly moving. He sees it as a true honor to be guided stereotactic techniques to “examine a exercises, having gradually transitioned from working alongside Marines, whose energy and centimeter-and-a-half of scar tissue in her leg.” primarily strength to endurance training. He passion overflow into every volunteer. It isn’t hard to see that the astonishing variety of happily points out that most of his injuries are age- He describes how emotional it can be after the patients such as these two is what he means by related, not necessarily caused by EDS. He still has flyover at the start of the race when the guns go off. “cool journey.” He asks, “What other profession not dislocated his shoulders, and does not hesitate A hush falls and the militarily injured Marines start can you have such a dichotomy yet still use the to attribute this to the buildup of muscle around the marathon at the front of the pack. He recalls same science and people skills?” his fragile connective tissue. “My connective tissue wives and husbands, mothers and fathers, pushing His waiting room is unique in that he has their injured sons and daughters in wheelchairs. purposely paired pediatrics, adolescents, Other Wounded Warriors make their way on geriatrics, and sports medicine together. In the prosthetic limbs. “They let the injured go first,” he medical community, this is out-of-the-box thinking says, emotion audible in his voice. “And it’s a huge to say the least. Yet these patient cohorts ultimately number—a hundred or more. And you think, this share the same needs: for a doctor’s office, x-ray is why we’re volunteering at the race.” labs, psychology department, nutritionist, and Dr. Lavallee’s longtime service to these heroes a fitness facility. The cost savings is immense and all his patients is dedicated, unflinching, and compared with the traditional model of two much appreciated. It is heartening to reflect that separate facilities for these patient groups. with all his fellowship work, he is also training the next generation of healthcare professionals to, like Enter AMAA him, always emphasize the “care” part of that word. AMAA member Robert Fawcett, MD (who was profiled in these pages in 2003), was Jeff Venables is the editor of Running & FitNews® Dr. Lavallee’s predecessor at Wellspan, starting the and a regular contributor to the AMAA Journal. Sports Medicine Fellowship there in York. When Fawcett retired and Mark took over, he continued the tradition of bringing the residents and fellows Mark’s son Sean and friends benefit from one of to the Marine Corps Marathon to volunteer in the his hobbies by getting to ride in a 1946 Willys CJ2A. medical tents. It is something he greatly looks forward to each AMAA Journal Fall/Winter 2016 19 46th Annual AMAA Sports Medicine Symposium at the Boston Marathon® April 15-16, 2017

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