The Clinic.

Q. Facts on Healthy Lipids

Can you give me more information on the difference between the effects of cholesterol levels and triglycerides on our health? What dietary or lifestyle characteristics could lead to elevated triglycerides when cholesterol levels are within normal limits? What guidance can you give to improve this kind of a blood profile?

Joseph M. Molloy, M.P.T.

El Paso, TX

A. Blood cholesterol levels, HDL, LDL, and triglycerides can be very confusing. If you plan to get your triglyceride levels tested make sure that you fast for 12 hours first because triglycerides fluctuate with dietary fat intake. Any one meal could artificially raise them. By fasting you will make sure to get the normal or baseline levels in your system.

You are right-triglycerides are sometimes found to be high when cholesterol levels are normal. What is most commonly seen in this case is that HDL is low or slightly lowered and triglycerides are high. While there is still debate, most sources say it is desirable to keep triglyceride levels lower than 200 mg. Levels over 200 put people at higher risk for heart disease.

There are two medical conditions specific to high triglycerides--hypertriglyceridaemias IV and V. They are genetic and often cause high triglycerides with low HDL. The first course of action is often diet and lifestyle changes. Medications can also be helpful, but it is very important to work out a plan with your doctor.

Other factors associated with high triglycerides are a diet high in sugars, high body fat, high alcohol consumption, and decreased physical activity. Some tips for lowering triglycerides: losing weight if overweight, lowering intake of sugary foods, increasing physical activity, and decreasing alcohol intake.

The best dietary advice you can follow is the Food Guide Pyramid. The pyramid offers a range of intake of the various food groups and shows what portion of your intake should come from each. Choose high-fiber foods from the grains, fruit and vegetable group, and low-fat foods from dairy and meat groups. Eating a wide variety of foods everyday is also very important.

Taggert J. Doll, MS., R.D.

Okemos, MI

Q. Help for Hamstrings

Several months ago I injured my left hamstring during a 10K race. Although this was the first time I've had a hamstring injury, I'm worried about it happening again. I have pretty good flexibility and include stretching in my training. I cross train with upper body workouts three times a week, run about 20 miles a week, and until recently, ran marathons regularly I still compete in shorter races, and often win in my age group (I am 62 years old). I do have a leg length discrepancy, although this has not hampered my running. I ran a l:l8 half marathon in the Pan American games in Venezuela. Any advice you can provide would be appreciated.

Jean-Francois Bulycz

Old Greenwich, CT

A. Your concern is very reasonable since suffering a hamstring injury definitely increases your risk for another. You have made an excellent recovery and by considering the following risk factors, you can improve your chances of remaining injury free.

Hamstring injuries are most common in sports that require sudden bursts of speed, sudden starting and stopping, or running over varied terrain (up and down hills). Fatigue probably also plays a role, with an injury being more likely to occur at times of severe fatigue. Other possible risk factors include strength imbalance, poor flexibility, inadequate warm-up, or inadequate conditioning prior to exercise.

Do not overlook hamstring strengthening. Make sure you balance quadriceps and hamstring development--quadriceps dominate hamstring strength in a ratio of three to two. It is also important to balance differences in strength on the left and right. Most individuals have a dominant leg. Difference of more than 10% can increase risk of injury of the weaker hamstring.

Most hamstring injuries occur either very early or very late in practice or competition. This emphasizes the importance of proper warm up and conditioning, and the risk created by fatigue. Do not neglect adequate warm-up, cooldown, and strength conditioning.

Use caution on stretching exercises. Overstretching can irritate the strained muscle. Avoid ballistic, forceful stretching of the hamstring muscles. Passive prolonged stretching offers the most benefit with the lowest risk of injury.

Congratulations on your incredibly successful running record.

Anna P Bettendorf, MD.

Wilmington, NC

A. Be sure to balance exercise with adequate recovery. Your running history suggests the possibility of persistent aid consistent overuse. Also, little as we may like to concede, there should be some allowance for decreases in exercise tolerance with aging. Make sure you allow for rest and recuperation periods. Ignoring these warning signs sets the stage for chronic overuse syndrome and injury. The benefits of exercise are great, but only if sufficient rest and recovery is planned as well.

Marvin Bloom, MD.

Burlingame, CA

Q. Run After Hammer Toe Surgery

I am a 67 year old runner logging in about 30 to 35 miles a week. I was recently diagnosed with Hammer toes on the second, third and fourth toes of my left foot. I was told that surgery would keep me from running for about six weeks. From the description of the surgery I am not sure it is something I want to do unless the long-term consequences without surgery are worse. So far it seems to be mostly a nuisance. On along run of more than 15 miles, the end of those toes get quite sore and occasionally I lose a toenail. Is this something I can just live with, or do I really need to go ahead with the surgery?

Harry Kittleman

Bend, OR

A. Hammer toes are bent at the joint close to the ball of the foot causing the toes to curl down and the top of the toe to be raised above the surface of the foot. That raised part rubs against the shoe causing pain. Not only are there different surgical options, but surgery is certainly not the only approach for treating a Hammer toe.

Hammer toe conditions can be either rigid or remain somewhat flexible. All Hammer toes are due to muscle substitution and imbalance. It is possible that a prior injury made you compensate in some way, which has now become permanent. Hammer toes usually progress through stages, starting out flexible and not painful. As they remain in the Hammer toe position, the toe will become stiffer and won't lie down in the shoes. This usually causes pain on the top of each toe. When the pain occurs on the end of the toes, you develop a claw toe. This is a deformity at both joints in the toe.

If your toes are still flexible and not stiff in the hammered position, you can try a half size larger shoe to see if your pain is relieved. You can also try to tape your toes straight for running to see if the pain subsides. If straightening relieves the pain, then surgery may be your best therapy. What happens with most Hammer toes is that they progress in deformity and rigidity, and become more and more painful.

There are two main types of surgery. One is called an arthroplasy and the other an arthrodesis. The first removes half of the first joint in your toe and it relaxes the toe. You heal faster, but have less stability with this surgery. The other procedure requires fusion of the first joint in the toe. It takes longer to heal, but is more stable. The toe next to your big toe should have the fusion done to keep stability for the big toe. The third and fourth toes can be treated with either technique.

Try conservative measures first, but the progress of your symptoms might demand more aggressive care. Best of luck to continue your excellent running program.

James E. Reeves, D.P.M.

Lawrence, KS

A. Hammer toes are sometimes simply caused by a sports shoe that is too tight or too loose in the forefoot Always make sure you get a professional fit for your running shoes. Another, treatment that can sometimes be successful is a simple procedure that cuts tight tendons and the joint capsule to release the contracted toe.

Marvin Bloom, MD.

Burlingame, CA

Q. Painful Achilles Tendinitis 

I have been running for the past 15 years with a weekly average of 25 to 30 miles, at about an eight and a half minute pace. I have developed swelling at the back of my foot about an inch from the bottom. It is extremely tender at the swollen area. Sometimes it hurts when I get up in the morning. It feels very tight if I squat or if I point my toes up toward my knee. Although the pain is not so severe that I can't run, it is really bothering me. Of course, I'm also worried that it will get worse and that I won't be able to run anymore. I've never been injured before, and I always do a complete stretching routine before and after running. I row and use the stationary bike for cross training. I replace my shoes every 500 miles or so. I have been a conscientious runner and can't think of what I should do to deal with this. I need some advice about treatment and prevention of this irritating problem.

Timothy H. Fredman

Hartland, WI

A. Your description of pain is classic for insertional tendinitis of the Achilles tendon. The pain often gets worse after exercising and can become constant. The tendon will become thickened, as this becomes more chronic. Sometimes a "divot" in the tendon will be noted. The chronic inflammation will lead to tightness of the back of your ankle and calf. In chronic cases the bone-tendon junction can become calcified with a spur that will extend into the tendon itself. Calcifications within the tendon may also develop. Chronic inflammation of the Achilles tendon can set the stage for more serious problems such as partial or complete rupture, which can take you out of the running for a long time.

Treatment is usually with anti-inflammatory medications (like ibuprofen), ice, massage, stretching, and modifying your activity. A simple heel lift in the shoes can take much of the stress off the injured tendon. A night splint can be very helpful as well. Sometimes physical therapy is necessary If this becomes more acute, or if there is a rupture, immobilization is often necessary. Orthotic devices are often helpful for the pronation that is frequently present.

Central to your problem maybe training issues including stretching and biomechanics. While the inflammation heals, non-weight bearing cross training should take the place of running. Although this is a very common overuse problem among runners, it demands serious attention to prevent a chronic situation or more disabling injury. See a sports medicine professional for a thorough evaluation and begin a supervised physical therapy program aimed to get you safely back to running.

Jennifer L. K Clark, M.D.

Columbia, MO

Ask the Clinic!

Are you bothered by an injury? Do you have a training or diet question? If so, ask The Clinic, in care of American Running Association, 4405 East West Highway, Suite 405, Bethesda, MD 20814, FAX [phone], e-mail [e-mail]. Free personalized sports medicine, training, and diet advice is an exclusive benefit for American Running Association and AMAA Members only. American Running has more than 255 Clinic Advisors representing more than 27 specialities. Include 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 will not be accepted. Include your name, address and phone number (even in e-mail). Letters cannot be processed without your name and mailing address. Responses usually.' take three to four weeks, but can take as long as five.