The clinic.

RUNNING SURFACE-THE HARD FACTS

Is it really true that concrete, being less resilient than asphalt, is harder on a runner's bones and joints? Given the weight of a runner, I would hardly think the impact forces would register a difference. An asphalt road surface is often cambered, which is a known risk for runners if you always run on the left, facing traffic. Since concrete sidewalks are usually flat, I would think that any difference in impact force would be moot compared to the "impact" of running on an angled surface.

Ed Langley

South Padre Island, TX

You are correct in both parts of your question. First asphalt is more resilient than concrete. And, asphalt roads are often cambered for drainage. Although your logic is sound, the two questions are really independent of each other. Concrete is very hard compared to almost any other running surface, and although it seems as if the marginal differences in hardness would be inconsequential, they aren't. Repetitive stress injuries occur due to the cumulative effect of impact forces. When you add those marginal differences between the impact of landing on asphalt versus concrete--stride upon stride, mile after mile, week after week, month after month--it can be significant.

On the other hand, running consistently on the same side of a canted surface is also a significant risk factor because it repetitively distorts the bio-mechanics of your stride. The lower foot tends to supinate by angling to the outside edge, and the higher foot tends to pronate by striking on the inside edge. Consequently, the pelvis is angled since one leg is functionally longer than the other. These factors can definitely contribute to injury, but you can usually compensate simply by reversing your direction over half of your course. Although good shoes can help with controlling impact forces, if you have a choice, concrete is best avoided as your predominant running surface.

CN/Ed.

MENISCAL KNEE PAIN

For the past few months, my right knee has been painful when I do a quadriceps stretch (pulling the foot back). It also hurts when I attempt to sit cross-legged. An MRI showed "myxoid changes in the posterior horn of the medial meniscus." I am seeing a sports medicine podiatrist who prescribed orthotics and specific running shoes. My orthopedist said the pain is from wear and tear. Do I need to stop running?

Marvin Ernst, D.D.S.

Tamarac, FL

Your symptoms are not uncommon among runners. Many runners do not have a completely neutral gait and show some degree of over-pronation or inward rolling of the foot during their stride. This pronation can cause an uneven distribution of forces at the knee and will often cause increased impact forces on the medial aspect of the knee. The medial meniscus is a horseshoe-shaped cartilage that acts as a shock absorber and hinge at the knee. With aging, the cartilage becomes less spongy and less resilient and is prone to degenerative changes, particularly if forces at the knee are not evenly distributed. Your MRI findings are consistent with degenerative changes due to wear and tear, which cause loss of normal resiliency and sponginess of the meniscus.

Because you've described pain only during certain situations, I'm assuming it is not hurting when you run at this point. And, because you only have minor changes at the meniscus, I do not think that this means you will necessarily have worsening problems. Often a good orthotic and appropriate motion control or supportive running shoes can correct gait problems that worsen wear and tear in the knee. I would recommend seeing a fitness specialist or your sports physician for some specific exercises that strengthen the muscles around the knee. Strong supportive muscles improve the alignment and distribution of forces at the knee. Given appropriate footwear, orthotics, and strengthening, you should be able to run pain-free for years to come.

Dennis D. Daly, MD.

Camillus, NY

GETTING THE CARE YOU NEED

I have been a runner most of my adult life and over the years have been plagued with several injuries, some of them recurring. I have often been disappointed in the care I've received and, in fact, have gotten some of my best advice right here from the Clinic Advisors. I have trouble getting doctors to evaluate me as a runner and provide the kind of total sports medicine care I need. Could you please give me some guidance as to the best way to work with a professional in order to really get the treatment a runner needs to solve a problem?

Mary Jo Tucker

Greensboro, NC

Despite major advances in medicine, health care today can be fragmented. A lack of continuity of care can arise because patients change insurance providers frequently and often have to change doctors as a result. There may also be gatekeeper problems as patients see specialists without anyone putting the big picture together. Unfortunately, the days of having one doctor deliver your babies, take out your gall bladder and manage your heart disease are over. Not only are health providers more specialized, but the bigger problems of cultural mobility and participating provider networks work against a solid, long term doctor-patient relationship. It would be ideal if your health care could be seamless--one office visit builds on the next and one treatment plan logically progresses to the next.

Fragmented care can often arise because one hand doesn't know what the other is up to. For example, the gynecologist may know a patient's history of endometriosis, which can cause back pain, but the patient may not understand the connection and fail to mention endometriosis to the orthopedist consulted for the backache. If your doctor doesn't know that you have endometriosis (or any of several other diseases that can cause back pain), you could be in for weeks or months of fruitless back pain and unnecessary care. Your history is the most important component in patient care and unfortunately the first to suffer when the system is stressed. The best way for you to correct these problems is to communicate thoroughly with your doctor.

Here are some tips:

1) Make sure your doctor is a qualified sports medicine professional. Most areas have sports medicine facilities where the health professionals are particularly interested in athletes and their sport-related problems. You can call the nearest university medical center and ask for an appointment at its sports medicine facility.

2) Tell your doctor everything. Connections can't be made if there are missing links.

3) Make sure you understand your diagnosis. You need the whole story so that you can see how it may fit in with your training habits.

4) Make sure you have a specific plan when you leave the office. "This is what to do for the next two weeks. If you don't see significant improvement, our next step will be..."

5) If you need to stop running while you heal, ask about cross-training activities so that you can remain as active as possible.

6) If you change doctors, make sure that your records and x-rays follow you to your new provider.

If you feel that your health care is a series of unrelated office visits, it may be time to make a correction.

Christopher Sorenson, D.C.

St Cloud, MN

SPORTS DRINK RUNS

I have repeatedly tried to use sports drinks during my long runs but it seems to run right through me. Within a half an hour of consuming the sports drink, I have to run to the bushes. I have tried to water down the drink but I get the same results. I know that I need to consume electrolytes and carbohydrates when training an hour or more, but what should I do?

George Murphy

Cleveland, OH

It is not uncommon to have this reaction to sports drinks. Many athletes simply cannot tolerate sports drinks of any kind. There are several reasons, but the most common is that the body has a hard time digesting the longer carbohydrate chains that are in sports drinks. These longer chains remain in the intestine undigested and cause water to be drawn in to dilute them. When extra water is present in the intestine, diarrhea occurs.

I would suggest that you stop trying to use sports drinks and stick to water for hydration. Foods such as apples, bananas, oranges, raisins, Fig Newtons, and pretzels can give your body what it needs during long, sweaty work-outs. Sports bars do a good job of providing energy and replacing electrolytes, but don't choose the high-protein variants--you might have trouble tolerating those. You may have better luck with gels but don't forget to consume eight ounces of water with each gel packet consumed.

Taggert J. Doll, M.S., R.D.

Okemos, MI

ARE YOU BOTHERED BY AN INJURY? DO YOU HAVE A TRAINING OR DIET QUESTION?

Ask The Clinic, in care of the American Running Association, 4405 East West Highway, Suite 405, Bethesda, MD 20814, FAX [phone], or e-mail at [e-mail]. Write a letter Including 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 cannot be accepted. All letters, even e-mail, must include your name, address and phone number. Responses usually take two to four weeks, but can take as long as five.