The Clinic.

KNEE NOISE

I am 48 years old and have been running for the last 18 years, usually three to four times a week alternating with crosstraining on a bicycle or elliptical trainer. I've recently returned to running after a layoff due to a broken toe and now notice that my left knee is making crackling or grating noises when I climb stairs. No pain so far, but is it something I should be concerned about and see a doctor?

Brian Curtis Hoard, D.D.S.

Charlottesville, VA

Most likely the noise you hear (crepitation) is an early form of patellofemoral syndrome also know as Runner's Knee. Patello-femoral syndrome involves poor tracking of the kneecap in the groove at the end of the femur. The quadriceps muscles, particularly the vastus medialis, control the tracking process. The vastus medialis is the muscle just above and to the inside of your knee. Patello-femoral syndrome can develop into a painful condition indicating inflammation of the soft tissues within the knee. Biomechanical problems, a tight iliotibial band, overtraining, canted running surfaces, hill running, and poor muscle function can contribute to the problem.

Without pain, you may benefit from a prevention program including flexibility for your iliotibial band, quadriceps, hamstrings, and gastrocsoleus muscles as well as strengthening of the vastus medialis and gluteal muscles. Specific strengthening exercises that are helpful include: quadriceps isometric contractions--tighten your quadriceps muscle with your leg extended, hold for six seconds, then relax for six seconds, repeat five to 10 times; straight leg raises; leg presses; leg extensions; short arc squat exercises without weights; and gluteal strengthening. You may also benefit from a patellar-stabilizing strap (available at pharmacies and running stores) that can help with patellar alignment. Replace running shoes frequently.

If you begin to have pain with your activities, going up or down the stairs, or getting in and out of chairs, make an appointment with a sports medicine physician to have your knee evaluated. The preventive measures listed should help you avoid progression of the problem and you may even notice the noise lessens or disappears.

Robert P Wilder M.D.

Charlottesville, VA

Make sure the seat on your bicycle is not too low and that you aren't using too much resistance for proper cadence-- both can strain your knee. When you use the elliptical trainer, make sure you keep a straight alignment with your foot, knee and hip.

Bruce Wilk, P.T.

Miami, FL

HONEY FOR PERFORMANCE?

I've tried various energy gels on a few of my long races and I believe they were helpful. However, they are costly especially since manufacturers recommend one packet every 30 minutes of training or racing. I've considered making my own using honey or corn syrup. Do you have any suggestions or recipes?

Ed Koundakjian

San Diego, CA

A study was done recently comparing different forms of carbohydrate gels on glucose, insulin and the perception of low blood sugar to honey when given before a workout. The honey appeared to be one of the most effective forms of carbohydrate to ingest because it has a milder effect on blood sugar. In another study, cyclists were randomly assigned to use honey, a glucose gel, or a flavored calorie-free placebo. The three "gels" were given prior to and every 16 kilometers during a 64-kilometer endurance test. Honey performed as well as glucose and both significantly outperformed the placebo. Another study suggested that honey speeds muscle recovery after a workout.

Water intake remains very important regardless of what carbohydrate source you are ingesting. Since honey does not contain electrolytes known to benefit endurance athletes, using a sports drink for fluid replacement would help to maintain electrolytes and sodium. The National Honey Board provided honey-based gel packs to runners at a recent 5K race. The ingredients listed 99% honey, and 1% magnesium, sodium, and cinnamon. That may give you some ideas for a home-brewed version.

Sarah Harding Laidlaw, R.D., MPA.

Glade Park, CO

TORN MENISCUS-FUTURE MARATHONS?

I am 42 years old and have been a recreational runner for most of my life. I suffered a torn lateral meniscus of my left knee. I do not remember the actual injury. Two tears were repaired surgically. There was also evidence of irregularity in the surface of the tibial plateau. How do I proceed and will I be able to run marathons in the future?

Paul Hunt

Miami, FL

The menisci, medial and lateral, are semi-lunar wedges of cartilage between the tibia (the major calf bone), and the femur (thighbone). They provide cushioning and contribute to knee stability. A tear in the cartilage may occur with a single traumatic injury, degenerative changes, or a combination of the two. Degenerative injuries are chronic and are usually associated with repetitive microscopic trauma of normal use or overuse. The aggressive repetitive pounding that occurs with running may accelerate changes. These changes, which involve roughening or fraying of the cartilage, don't usually cause symptoms in the earliest stages. Eventually the breakdown is severe enough or large enough to bring the injury to your awareness. There is no evidence that running, per se, causes knee degeneration, but running can accelerate a degenerative process once it begins. You will need to work closely with your doctor because your doctor knows best the extent of the injury and rehabilitation. If your doctor clears you to r un, then progress very slowly. Correct any biomechanical problems that may have contributed to the original injury. Ice your knee regularly to reduce post-activity swelling. Exercise only within a pain-free window--do not push yourself to the point of pain or swelling. Replace running shoes frequently, run only on softer surfaces, use arch supports if you need them, strengthen the quadriceps, stretch the hamstrings, and maintain a healthy diet and weight. Although it isn't possible for me to say whether you will be able to run a marathon again, the mileage necessary for training may challenge your meniscal repair and accelerate the degeneration of your knee.

Robert Scott, MD.

San Diego, CA

RUNNER'S ANEMIA

I am a 38-year-old distance runner maintaining about 50 miles a week during off-season and increasing to 80 to 100 miles a week during marathon training. Recently I was not able to complete training runs due to profound fatigue. According to a hematologist, my iron level was about 10, but my red blood cell count was low. Currently I am taking 300 mg of iron sulfate with vitamin C three times a day for three months. I've been on the regimen for about two months and was hoping to feel a lot better by now.

Rhonda Davidson-Alley

Tamuning; Guam

Endurance athletes tend to have lower hemoglobin concentration than their sedentary counterparts. This "false anemia" is referred to as sports anemia and is a misnomer. Sports anemia is a beneficial adaptation to regular exercise, which increases red cell production and survival. The red blood cells are in charge of transporting oxygen to body tissues and so the oxygen carrying capacity of the blood is enhanced. Exercise also conserves the body's salt and water causing an increase in plasma volume that dilutes the red blood cell concentration. This rise in plasma volume increases the cardiac blood output and decreases blood viscosity causing more oxygen to be delivered to muscles. The increase in plasma volume is proportionally greater than the increase in red blood cell mass and so red blood cell concentration levels appear low without representing true anemia.

Endurance athletes can also destroy a small number of their red blood cells during training and competition, which may affect their performance. This is called exertional hemolysis or footstrike hemolysis. Usually this problem is so mild and the body compensates so fast that an anemia does not develop. Treatment involves improving the conditions that contribute to bursting red blood cells. Improving shoe cushioning and choosing a softer running surface can lessen impact forces and decrease footstrike hemolysis.

However, athletes, especially females can also develop true anemia, most commonly due to iron deficiency. The main cause of iron deficiency anemia in an athletic woman is too little dietary iron to meet physiologic needs. Women who lose more than 60 ml of blood per menstrual cycle are more prone to iron deficiency, which can negatively affect athletic performance. You can prevent iron deficiency by eating more lean red meat, dark poultry meat, and cooking in cast iron skillets to leach iron into food. Avoiding caffeine with meals and including a vitamin C-rich food source at each meal enhances iron absorption.

Assuming that your diagnosis of iron deficiency anemia is correct, a three-month course of iron therapy should restore your red blood cell count to normal and replenish your iron stores. However, the profound fatigue you have experienced may have another cause such as overtraining, illness, hypothyroidism, or other problems. I recommend taking a hard look at both your diet and your training habits. Your mileage volume consumes an extraordinary amount of calories and fluids. I have seen athletes suffering from decreased performance, fatigue, and muscle aches just from improper diet and fluid replacement. I recommend an evaluation by a certified dietitian to make certain your training needs are being met. It is also very important to increase mileage during racing season gradually enough to allow for recovery and training gains. Doubling your mileage requires a long lead up in order to avoid overtraining syndrome.

Carlos Jimenez, MD.

Guaynabo, Puerto Rico