The clinic.

Bruised Shins After Workouts

I am a fitness walker, age 56, 215 lbs. I average 10 to 20 miles per week. My marathon PR is 5:38. Recently, after long excursions (10 to 24 miles) my medial shins have irregularly shaped, dark red splotches on them. They last for a few days and are not painful. It looks like blood under the surface of the skin. I take an 81-mg aspirin, 10 mg of Lipitor, 25 mg of a prescription NSAID, and 8 mg of Cordura daily along with multiple vitamins. My other regular exercise is light weight lifting and a short swim one day a week. I suffered a myocardial infarction (MI) seven years ago and have no symptoms today. I have excellent blood work from one month ago.

Frank Pirelli

Obviously without seeing the splotches there are limitations in what I might be able to reliably diagnose. I do, however, suspect the splotches are, as you suggested, due to bleeding under the skin related to the trauma of your long workouts. NSAIDs and aspirin interfere with the function of platelets, the cells that make blood clot. They may further contribute to this problem. If the splotches are due to trauma, their appearance should evolve from a dark red purple to a more yellowish green-brown over a several day period, similar to the changes in appearance someone with a black eye goes through.

There are some uncommon medical disorders associated with splotches over the shins or that can predispose people to bleeding, so make sure you check with your doctor just to be certain that something else is not the cause. If your doctor determines that there is no other cause, there is no reason to alter your exercise program if these splotches are only cosmetic and are not causing any discomfort. Although your aspirin use may be contributing to the appearance of these legions, you should keep taking aspirin since you have had a heart attack in the past.

Todd Miller, MD

Although the condition you describe could very well be the result of bruising of the tendons in your shins, it is certainly important, as noted above, to see a doctor to be sure there are no clotting problems with your blood.

Dennis Daly, MD

The combination of low-dose aspirin, a daily NSAID, and heavy physical activity are probably enough to cause a tendency toward bleeding into the skin, which means these areas are likely bruises. I would consider trying acetaminophen in lieu of the NSAID, and see if your bruising ceases. If it continues, further evaluation by a hematologist is probably indicated.

William M. Simpson, Jr., MD

Hyperkeratosis is Hereditary

On the heels of both my feet, as well as the area just below my toes on the bottom of each foot, I have rock-hard tissue that I have attempted to treat to no avail. On the advice of both physicians and podiatrists I have applied moisturizing cream three times a day, put cushioned insoles inside my shoes, soaked my feet in both hot water and hot water with Epsom salts, and rubbed my feet with a pumice stone. This last treatment in particular was a lot of effort and yielded almost no result. The only treatment that has had any results worth noting was rubbing vitamin E oil into the hard areas three times a day. While this appeared to soften my feet, it was such a mess that I deemed it not worth it. The oil got inside my shoes, socks, bed sheets, etc. and there was simply no way to contain it. Any additional solutions to this problem, which I suspect many people have had, would be greatly appreciated.

Richard DeAngelis

I have had success treating excessively hard skin (known medically as hyperkeratosis) with the following regimen:

1. Apply Carmol-40 lotion twice a day to all areas. This is a prescription-only lotion with 40% urea, vitamin E, lactic acid, and zinc.

2. Wear cushioned insoles, as you have done, but also non-leather soled shoes.

3. Wear socks at all times.

4. Do not walk barefoot.

5. See a podiatrist every two months initially for paring of the legions with a blade; after this you might be able to lower the frequency of the visits.

This is a hereditary and non-curative condition but if you are diligent it can be managed well. With this treatment you will also have the peeling of skin--which can't be avoided until the condition gets better. Later you can also use a lotion with only 20% urea if you so choose.

David A. Lief, DPM 

In addition to Carmol-40, there are over-the-counter lotions or creams, such as Eucerin Plus, that contain alpha hydroxyls (lactic acid and uric acid). Alpha hydroxyls are gentle acids that soften the dry, hard skin.

Paul Langer, DPM

The Pros and Cons of Hip Resurfacing

In a few weeks I am having a hip resurfacing--as opposed to a hip replacement--operation. I have been told that there will be no restrictions on physical activity after the initial recovery. Do you have any feedback on this procedure?

Bob Wilhelm

Hip resurfacing is less traumatic than hip replacement surgery. Since only the femoral portion should be involved, activity may not be affected in the same way that it is with total hip arthroplasty. Normal post-operative hip precautions such as extreme internal and external rotations of the joint are not as much of a factor. I feel that your primary recovery issues will be strengthening and maintaining range of motion.

Ron Kleinman, PT

Hip resurfacing has been around for at least 25 years. It has some theoretical advantages. However, those advantages were never really confirmed in clinical practice. In my opinion, the only argument for a surface replacement over total hip arthroplasty is that if the hip resurfacing fails, it is easier to revise to a conventional total hip than to revise a conventional total hip to another conventional total hip. There was always an unacceptably high rate of loosening, avascular necrosis, and failure with the old resurfacing designs. One of my patients (age 45) had bilateral hip resurfacing at a major university, and both sides failed within two years and I had to revise them to conventional total hips. The older metal ball and plastic socket was inferior to the newer metal-on-metal designs of the last eight or so years.

There is still, in my opinion, an inevitable problem of avascular necrosis, where the bone underlying the prosthesis simply dies due to the disruption of the normal vascular supply by the metal cup. I think this is an unavoidable complication which will never be solved because of the intrinsic limitations of the anatomy. Most series report at least a 10 or 15% incidence of this complication.

I also caution you that I know of no published literature or scientific study that supports unlimited physical activity after any hip prosthesis, whether conventional total arthroplasty or resurfacing. While you can certainly do many things after major hip surgery, high impact activities such as running, jumping, basketball, and tennis definitely increase the chances of loosening. It's true that Mike Ditka played handball after his total hips, but he also had both sides revised within a few years of the original surgery.

If you are less than 55 years old, then a surface replacement has a few theoretical advantages, however limited. If you are older than 55, I see absolutely no benefit to a surface replacement. A conventional total hip arthroplasty will be far more predictable and will allow you to do everything you can do with a surface replacement. I do not believe there is any functional advantage to a surface replacement whatsoever. The restrictions and limitations after surgery are exactly the same. I am curious what advantages your surgeon feels the surface replacement will give you; in my opinion, there is a mild but definite increase in potential complications for very little potential gain.

Klaud Miller, MD

Running on Ritalin

I am wondering about the effects of Ritalin, for Adult Attention Deficit Disorder, on heart rate and running performance. I coach adult runners and have a runner who tells me his heart rate was very high during his college cross-country training: 150 to 170 during an easy jog. I requested a physician's clearance from him--am I being overly cautious?

Jim Bonaparte

Since Ritalin is a stimulant (of adrenalin and other catecholamines), it can increase blood pressure and heart rate. However, as a practical matter, the increases are variable and of the order of 5 to 10 mmHg of blood pressure and 5 bpm for heart rate. Most of the reports in the medical literature are about children.

My advice would be that an exercise program can be pursued. I would monitor heart rate and proceed cautiously at first; you can then increase intensity and duration of training.

Charles Schulman, MD

This stimulant and others similar to it can result in a somewhat increased resting heart rate. However, these drugs should not have a significant impact on the safety or effectiveness of running for fitness. I am unaware of any information about the effects on competitive performance. Although the scenario you describe sounds safe to me, I share your concern for the safety of intense training in adult runners who are taking medications on a regular basis. I certainly think it is reasonable to ask for a note from your runner's physician, ensuring the appropriateness of this sort of workout.

Theodore N. Keltz, MD