The Clinic.

Over the past couple of years I've been having trouble with a hamstring muscle that I injured by over-stretching. I have read that "cross tissue massage" can be good for this type of injury. What do you think?

Jim Hamerstadt

Cincinnati, OH

Transverse friction or cross fiber massage can be beneficial for muscle tears In your hamstrings. A strain or a microtear in a muscle causes some of the fibers to part. Scar tissue forms and adhesions develop causing crosslinks in the tendons that disrupt the longitudinal arrangement of the tendons. These microscopic adhesions cause pain when the muscle contracts. The adhesions can be broken up or ruptured with deep transverse friction massage allowing the tendons and muscle fibers to return to their normal parallel configuration. Since the origin of the hamstrings lies deep under the large gluteus maximus (buttocks) muscle it is sometimes difficult to effectively rupture the adhesions formed and hamstrings tears in this area require a lengthy recovery time.

Make sure you maintain flexibility of the hamstrings with adequate stretching and consider adding strength training to your routine, specifically for your hamstrings. Runners often suffer some form of muscle imbalance. Often the quadriceps overpowers the hamstrings and sets up a situation for muscle injury to the hamstrings. Add hamstrings strengthening exercises like hamstring curls with weights and straight leg raises with weights while lying on your stomach.

Carol Hamilton Zehnacker, P.T.

Frederick, MD

Whenever you suffer a chronic condition, make sure someone evaluates the big picture. Chronic hamstring problems can be the result of leg length differences or pelvic alignment problems, not to mention possible training errors.

Mitch Goldflies, M.D.

Chicago, IL

PREGNANCY AND EXERCISE HEART RATE

I have been running for the last seven years, including a marathon and several half marathons. I usually run or crosstrain for an hour six days a week. I am now eight weeks pregnant and my health care provider advised me to keep my heart rate at no more than 140 beats per minute while exercising. I don't believe that I could continue at my current level of exertion and keep my heart rate that low. I want to stay in shape while I'm pregnant and I thought current recommendations allowed women to exercise more vigorously during pregnancy. Do you have any advice?

Melissa Edwards

San Diego, CA

The number of very active pregnant women is increasing all the time. The medical literature confirms that women who continue to exercise during healthy pregnancies have a much lower incidence of complications compared to non-exercising controls. There is also evidence that the baby benefits as well. While there are certain restrictions and medical conditions that may arise during pregnancy that would preclude strenuous exercise (including, for example, premature labor or placenta previa) for the majority of women exercise during pregnancy is beneficial.

A key factor is your level of fitness and activity before you became pregnant. In your case you are clearly very fit and accustomed to a high level of activity and exertion. Because of the wide variations in heart rates among individuals, it would be difficult to give a specific heart rate recommendation that would apply to everyone. A better way to monitor your level of exertion may be to evaluate your perception of how hard you're working, aiming at maintaining and not exceeding your pre-pregnancy perception of effort. It is

extremely important, however, that you continue to carry on an open dialogue with your physician regarding your activity and the ongoing changes in your pregnancy. You might like to refer to Exercising Through Your Pregnancy by James F. Clapp, III, M.D., who is considered the reigning authority on exercise and pregnancy by the medical community (1998, Human Kinetics, Champaign, IL, 245 pp. $16.95).

J. Ron Eaker, M.D.

Augusta, GA

TOE NAIL TROUBLES

About two months ago, I clipped a toenai too close, and possibly clipped a bit of skin. It has been tender to touch for most of that time, and turned black shortly afterwards. It is now very tender and I think the nail is about to come off. What can I expect? Will a new nail grow back? Do I need to take any precautions now or after it comes off? I am currently running 30 to 35 miles a week and hope that there is no down time to recover from this mishap.

Jim McConnell

St Petersburg, FL

Cutting the nail too close to the skin inflamed the skin. The skin then began to push against the nail, causing the discomfort. With enough swelling the pressure can cause bruising (the black color you see). If the area is red and swollen, infection is likely and you should have it checked by a podiatrist or an orthopedist sooner, not later. The bruising causes the nail to separate from the skin, so the loosening you describe isn't surprising. If there isn't any redness or drainage, you most likely have a new nail growing in from the previous irritation and this loosens the old nail as it grows out. If it doesn't hurt, leave it alone and the loose nail will eventually fall off without trouble.

However, if there is pain, see a doctor and have the nail removed. Removal of a painful nail takes less than a minute and with local anesthesia it is not very painful. Usually the pain of the nail is much worse than the procedure to remove it. Removing the loose nail will get rid of the irritant causing your pain and shouldn't cause any loss of training.

Gene S. Mirkin, D.P.M.

Silver Spring, MD

As long as there is no infection (redness, throbbing, or drainage) leave the old nail in place; it guides the new nail growing in behind it. If the nail is removed, it will take eight to 10 months for the new nail to grow back, so you might continue to have problems with an inflamed nail bed. If the old nail is not irritating and there is no infection, put a BandAid or flat tape over it to keep it from catching, and continue running.

Harry Hiavac, D.P.M., M.Ed.

Mill Valley, CA

STRESS-FRACTURED TRAINING

I am 48 years old, a 30-mile-a-week runner, and have recently suffered a tibial stress fracture. I am assuming this happened because I increased my training intensity with too much speed work My orthopedist told me it would take six weeks to heal. How can I minimize my down time? I stretch, use the Nordic track and bicycle, eat well and take vitamins.

Scott Ebert

Fridley, MN

Most simple stress fractures, occurring in the medial shaft, will heal with six to eight weeks of weight bearing rest--you may walk but not run. Certain tibial stress fractures, such as an anterior tibial stress or a medial malleolar stress fracture, however, are more serious and generally do require more extensive rest, possible immobilization and even surgery depending on the severity. Stress fractures occur in most instances because training increases were simply too much for your bones to adapt to at the time--too much, too fast, too soon.

During rehabilitation non-impact forms of crosstraining are usually fine. I prefer deep water running as a form of cross training, since it provides a great cardiovascular workout without impact. Deep water running mimics actual running for your muscles. You might also work with a physical therapist to learn strengthening and stretching exercises for the muscles that support the area of the stress fracture. Any abnormalities in your biomechanics or running gait can be identified by a physical therapist as well, sometimes using a videotaped gait analysis.

After all the pain is gone, X-rays confirm healing, and there is no localized tenderness at the fracture site, you can resume running. However, it must be done in a very gradual fashion. Start a walking program, advancing after a few weeks to a walk-jog program, ultimately advancing to a running program. For the first several weeks of this program your mileage should be extremely low and your emphasis for cardiovascular conditioning should be on deep water running and non-impact forms of cross training. Although this can be frustrating in the early going, the ultimate goal of returning to a full level of training can be reached earlier. A more aggressive early running program puts you at risk for a recurrent stress fracture.

Discuss these measures with your physician and be sure not to transition back to running too quickly. Patience will pay off in the long run as you will hopefully get back to your desired level of running without another interruption in training. In the future be sure to include plenty of rest and recovery in your training in order to avoid the consequences of too much, too soon, too fast.

Robert P. Wilder, M.D.

Charlottesville, VA