The Clinic.

FOR MEMBERS ONLY PERSONALIZED SPORTS MEDICINE, TRAINING AND DIET ADVICE

255 CLINIC ADVISORS REPRESENTING MORE THAN 27 SPECIALITIES

STALE AND WONDERING WHY

Every runner experiences an "off day" occasionally. For no apparent reason, running seven easy, flat miles feels like running 17 miles uphill. Everything returns to normal by the next run. Assuming the runner is eating properly, sleeping well, and is in good health, what could cause these occasional lapses? And what's the remedy?

Duane Morse

Phoenix, AZ

I wish I had a definitive answer to your problem. Almost everyone has off days from time to time. Some possible causes include low level illness, overtraining, staleness, and boredom.

Overtraining in its early stages may manifest itself in an occasional decline in performance, decreased motivation, or diminished enthusiasm for the sport. Simply allowing yourself more rest days or alternating heavy with light training days may alleviate the symptoms of overtraining.

Staleness results from a lack of variation in your training. After a period of time, the body will adapt to a particular exercise routine and will need a change of pace to continue to improve fitness levels. An alternative form of cardiovascular exercise worked into your running schedule should help you avoid this problem.

Boredom is what I consider the mental form of staleness. Not only does your body stop improving with the same routine day in and day out, you lose mental focus when there are no new challenges. Again, variety in training routine, type of exercise, and environment may prevent boredom.

Runners may become gradually dehydrated over a period of days and then feel fatigued. This often happens in cool weather when you may not be forcing fluids the way you do in warmer weather, and may not be aware of water lost during winter running.

Finally, none of the above may be the culprit for an off day. We are complex organisms with a multitude of possible causes for being off our game from time to time. Chances are that adequate rest and variety in your exercise program will help you to minimize the number of off days you experience. However, if you continue to have problems on a regular basis or with increasing frequency, check with your physician to rule out any underlying health problem.

Maribeth Salge, M.A., PT Cocoa, FL

You may think sleeping well for seven or eight hours a night is all that is needed to assure that you are well rested. Fatigue can be far more insidious for athletes. On those days that your legs feel heavier than normal, your heart pounds when you've barely exerted yourself, and a flat seven feels like 17 uphill, I would bet money that fatigue is the culprit.

Remember that all training gains are made during recovery and if your body is being challenged with high intensity training day after day, training gains are traded for drained and depleted energy reserves. Your body may be pleading for a day off (and for more intelligent training overall). The feeling of heaviness and fatigue is probably the only way your body has to communicate the need for rest and shouldn't be ignored--it should be respected. Shoot for light days to alternate with more intense days and incorporate an easy week into your plan every six or seven weeks. Ed.

HORMONE REPLACEMENT CONTROVERSY

I am a 50-year-old woman, in great physical shape, and a successful marathon competitor. I am fully aware of the benefits of weight-bearing exercise on my bone strength and as I get closer to menopause, I was looking forward to starting hormone replacement therapy to aid in that process. I've read some new studies that scare me--am I really increasing my risk of breast cancer? What should I do?

Sarah McCarthy

Minneapolis, MN

Menopause (average age 51.4) is marked by the cessation of menstrual flow and is directly associated with a significant decrease in female hormone levels. Manifestations of decreased estrogen include obvious symptoms such as hot flashes, sleep disturbance, decreased sex drive, and emotional irritability. Replacing estrogen greatly improves all of the symptoms, and in addition, has benefits for long-term health including increased bone density as well as protection against heart disease.

On the down side, estrogen therapy increases the risk for uterine cancer, but adding progesterone negates this risk. Thus, a combination of estrogen and progesterone for hormone replacement has become standard therapy for many post-menopausal women over the last twenty years.

There has been a concern for quite some time that this combination therapy might increase breast cancer risk. This was addressed in two recent large studies, one published in the Journal oldie American Medical Association (January 26, 2000) and the other in the Journal of the National Cancer Institute (February 16, 2000). Both reached similar conclusions. Compared to no therapy, estrogen alone increased breast cancer risk approximately one percent per year of use. Adding progesterone increases breast cancer risk between five to eight percent for each year of use (while decreasing uterine cancer risk).

Each woman must make a careful risk-benefit analysis. Do you have a strong family history of breast cancer? If so, you might feel comfortable treating early menopausal symptoms with estrogen-progesterone combination for a few years, but not continuing indefinitely. On the other hand, if you have a bigger concern about heart disease or osteoporosis, long-term therapy might still be reasonable.

If you are in great shape, you are already one step ahead on the bone density and healthy heart scale. Don't forget the importance of a low-fat, well-balanced diet, supplemental calcium, and avoidance of tobacco products and excessive alcohol. New studies are examining the benefits of plant estrogens such as those found in soy products, which may offer some of the benefits of estrogen without promoting breast cancer. You and your doctor should evaluate the relative risks to make the right choice for you.

Richard S. Newman, M.D.

Washington, D.C.

FOOT AGGRAVATION

I am 44 years old and run most days from three to ten miles. I have had an ongoing aggravation on the bottom of my foot. When I run I have the sensation that a piece of gravel is working its way into the sole of my foot--not fun. There is a quarter-inch depression with a dry, roughed up center, which always feels raw and sore. There is a callus around the sore area that has some black specs in it. A podiatrist examined me and said it could be a calcium deposit or a wart, but didn't really offer any treatment. I would love to get rid of this problem since it really impedes my running.

Joe Sciolino

Chicago, IL

The lesion you described is a callus, a wart, or a porokeratosis. A callus results from friction with skin thickening in which you can see your normal skin lines running through it. Simple debridement or scraping can reduce the callus. Sometimes, placing a pad under the lesion will help slow its return. You should understand that it is likely to return on a fairly regular basis but can be controlled with proper foot care.

A wart is a lesion caused by a virus that continues to grow in both depth and width. It usually has a depression that you described and the black dots seen within the wart surface are blood vessels. If it is a wart, one way to resolve it is by topical chemocautery. A chemical is placed on the surface of the lesion every several weeks. The problem is that it can take months to treat and sometimes is not successful. The lesion can also be excised. This can take from two to five weeks to heal and can be very painful. Freezing the lesion is also painful and usually fails due to the thickness of the skin on the bottom of the foot. Another alternative is pulsed-dye laser. This works by sealing off the blood supply to the lesion. It is done without anesthesia and has no resulting disability. It usually takes between four and six visits, about three weeks apart, and usually does not interrupt your running schedule or cause pain.

A porokeratosis is similar to a wart but is not caused by a virus. It does not appear with black dots in the center. If the lesion is a porokeratosis, unfortunately, your only recourse is to have it surgically removed. What you need is a good podiatrist willing to give your condition the attention it requires to get you running comfortably. Find a doctor who understands athletes and is experienced in pulsed-dye laser treatment and you'll soon be up and running pain-free.

Gene S. Mirkin, D.PM

Silver Spring, MD

ARE YOU BOTHERED BY AN INJURY? DO YOU HAVE A TRAINING OR DIET QUESTION?

Ask The Clinic, in care of The American Running Association. 4405 East West Highway. Suite 405. Bethesda, MD 20814. FAX [phone]. or e-mail at [e-mail]. Write a letter Including as much relevant information as possible about you (age. weight. etc.) and your injury (type and location of pain), training schedule (typical weekly workouts, pace, surface). athletic and medical history sole wear, recent changes in training. etc. Type or print your letters. Hand-written FAXed letters cannot be accepted. All letters, even e-mail, must include your name, address and phone number. Responses usually take three to four weeks, but can take as long as five.