The Clinic.

Q. Bundle Branch Block 

I am a 50-year-old male. I have been running for over 20 years and have completed several marathons. In spite of my exercise and a good diet, I have high cholesterol (250) and have been taking between 1,000 and 1,500 micrograms of niacin per day, which has worked well.

At my last physical examination and EKG my doctor told me that I have an incomplete right bundle branch block and a mild sinus arrhythmia. My physician was not concerned about either finding, but I have a few questions. Will this cause future problems? Is it just a natural part of aging? Do diet or other factors I can control affect these conditions? Do you have any suggestions, or should I just forget all about it?

Bobby Levin

Baltimore, MD

A. The development of sinus arrhythmia is totally benign. I doubt that it is an age-related phenomenon, and it is unlikely to develop into problems in the future. It is certainly not likely to be affected by diet or anything else that you can control. In general terms, the presence of a mild sinus arrhythmia is really a finding of increased vagal tone. This can be a feature of athletes' hearts. It is probably a good sign and reflects your 20 years of running.

Incomplete right bundle branch block is a common normal variant found on electrocardiogram and is also another finding that is often associated with an athletic heart and is of no consequence. My only concern is that it sounds as if you are having serial evaluations and if your electrocardiogram changes with time and evolves into a complete right bundle branch block in the future, then it needs further examination. In about 70% of people, a complete right bundle branch block also has no association with any structural heart disease. Yet, in a small proportion it may indicate some underlying heart disease. If your EKG evolves into a complete right bundle branch block then it may be necessary to do some further investigating with an exercise stress test or a nuclear stress test. But this does not seem to be the case at this time.

Overall, the findings of an incomplete right bundle branch block and mild sinus arrhythmia are signs of an athletic heart, and they are not likely to develop into an unhealthy condition. I believe you should not worry about it and continue with your excellent running. However, a 50-year-old male with high cholesterol should work toward healthy lipid profiles. If your family history includes heart disease, your doctor may want to consider using cholesterol-lowering drugs in addition to diet and exercise. It is certainly reasonable to get a complete check up once a year to catch any changes that may need attention.

Anthony P Goldman, MD.

Tampa, FL

Q. Knee Clicking and Pain

Whenever I run, climb stairs, work out with weights, or bend my knee I hear a clicking or grinding sound. When I run or climb stairs, my knee will start to hurt after about five minutes. I have heard that this means there is cartilage damage. Is this true? Should I be concerned?

Karen McClelland

Mobile, AL

A. Pain in the anterior or front of the knee is a very common condition, which is often due to changes in the mechanics of the joint between the knee cap and the thigh bone, known as the patellofemoral joint. This may progress to a condition called chondromalacia of the patella, which is damage to the surface cartilage of this joint.

Many people experience some popping sounds in the knee with certain activities, which may not be very significant, but if there is pain you should see a doctor for diagnosis and treatment.

Temporary pain relief can usually be obtained with heat, ice, acetaminophen, or over-the-counter anti-inflammatory medications like ibuprofen. However, be cautious of these medications, particularly if you have a medical history of stomach, liver, or kidney problems. In any case, unsupervised use of the medications should be limited to no more than one or two weeks.

Treatment for a runner must include examination of the shoes. They should be supportive of the arch and not have been used for more than about 300 to 500 miles. You should stretch the muscles in your legs very carefully including your heel cords, your hamstrings, and your quadriceps as tightness of all of these can increase the pressure on the front of the knee.

Finally, you need to strengthen your quadriceps, particularly the vastus medialis, which is the prominent muscle just above the patella on the inner side of the thigh. There are a number of ways in which this muscle group may be strengthened. You should start with isometric exercises or quad sets in which the quadriceps is contracted and held for several seconds repetitively for three sets of 10 to 20 reps, concentrating on recruiting the vastus medialis. Runners need this muscle to be active during forceful weight bearing activity. Once the initial pain subsides, you can start doing partial (quarter) squats keeping the knee in a neutral or straight position over the foot.

If these measures are not effective, see an orthopedist who can evaluate your knees and provide accurate recommendations.

Stuart Weinstein, MD.

Seattle, WA

A. A physical therapy program can be very helpful in treating anterior knee pain. Strengthening of the quadriceps, as well as flexibility of the hip and thigh muscles, is needed to dynamically control the way the kneecap glides or tracks. Sometimes orthotics are needed to improve foot alignment, and usually training adaptations need to be made to avoid pain. I suggest a sports physical therapy exam and sports medicine orthopedic assessment.

Steven Hoffman, L.P.T.

Sewickley, PA

A patellar-stabilizing neoprene wrap can help maintain proper tracking of the patella in the femoral groove. (-Ed)

Q. Really Cold Running

After 10 years in Hawaii I have relocated to Alaska--from tropical to 13 degrees at high noon--what a switch. As a runner for over 20 years, I'm at the gym every day wondering, "can I brave the cold?" The local running store advises to layer my clothing and I'm good to go. I don't see any runners on the roads to reassure me that my lungs would survive. Is there a minimum temperature or wind chill below which I should stay indoors?

Charlene Grant

Anchorage, AK

A. Welcome to Alaska. I have been living and running in Fairbanks for the past 36 years. According to the records, I'm the oldest competing male runner in the interior of Alaska at nearly 72. I have run in weather as cold as 50 degrees below zero.

Covering your face protects against frostbite and warms the air you breathe as well. I use a two piece set that includes a stocking cap for my head and a balaclava for my neck and face, which can be pulled up over my nose. These come in various materials but I like the polypropylene and acrylic better than wool or cotton. I use lightweight rubber slipons over my shoes, which are equipped with four stainless steel spikes (check with climbing suppliers for these) to keep from slipping on the ice. You will need to gain experience with what works best for you. Start out close to home running loops without getting more than 10 minutes away from shelter, just in case you haven't gotten it right. But I'm living proof that running is possible all year, even in Alaska. Enjoy.

Jack Townshend

Fairbanks, AK

A. Your hardest task will probably be to put your foot out the door. You can mix inside workouts with outside to disperse with boredom, and link up with some pals.

Priscilla Welch

Tabernash, CO

Q. Surgery for an Inguinal Hernia

I have surgery scheduled to repair a right inguinal hernia and would like your advice about recovery and rehabilitation. When can I resume running? When can I begin abdominal exercises like crunches? When should I begin stretching? How about hill work and speed work? How long should I keep distances short and paces slow? I can be patient during my recovery. I really want to keep myself healthy and not get hurt by coming back too soon. On the other hand, I certainly don't want to prolong inactivity.

Gary J. Raby

Lewiston, NY

A. An inguinal hernia is the result of a defect in the abdominal wall at the groin allowing a loop of intestines to protrude. It can be painful, certainly annoying, and sometimes dangerous if the loop of bowel twists preventing normal bowel function. It can usually be repaired using a laparoscope in which case your hospital stay is short, the surgery is minor, and recovery is relatively quick. Sometimes hernias are repaired with a larger abdominal incision.

It is very important to know whether your repair will be performed laparoscopically or through a larger abdominal incision. Recovery for the two procedures is very different. I will assume you are having a laparoscopic repair since that is the more common approach and is usually an outpatient procedure. Running can probably be attempted within two to four weeks but at a much lower intensity than you are used to, even beginning with a walk/jog. (An open, abdominal repair would require at least six to eight weeks of recovery before running could be attempted.)

You may want to consider some non-impact cross training such as pool work or stationary cycling to help maintain your cardio-respiratory fitness at the beginning. Then use a slow but sure approach of increasing your running stress from a comfortable pace over a much-reduced mileage and then increase 5% to 10% per week. Once you are running comfortably at slow paces and on easy terrain for a few weeks, you can begin a gradual increase to faster, more intense training adding hill work and speed work over a several week period. You should listen to feedback from your body and remember there are two considerations: healing from your surgery and reconditioning after a layoff. No matter how good you are feeling, always keep the 10% rule at hand--never increase speed or intensity by more than 10% per week and never increase both at the same time. Establish an endurance base and follow with speed or power workouts when you are totally comfortable.

Stretching the lower extremities can begin right after surgery, even the very next day. But weight training, abdominal crunches, or leg lifts should be held off for three or four weeks after surgery. It always makes sense to err on the side of caution. A gradual comeback will re-train your muscles and cardiorespiratory system without risk of injury. The end result will find you as fit, strong, and fast as you were before. You will be surprised how fast your return is by taking the slower approach.

Edward Vivoda, MD.

Marysville, MI

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.