The clinic.

Sore Hamstring Solutions

I am a 5' 3", 55-year-old female weighing 115 lbs. I have run two half-marathons and would like to continue to run long distances, eventually including marathons. After each race, however, my hamstrings are sore. Can you recommend exercises or workouts that will strengthen my hamstrings and prevent them from remaining sore for up to a week afterward?

Sue Caldwell

Pipe Creek, TX

I suspect you may be overusing your hamstrings. While the hamstrings are very active in the normal running gait, my experience is that they are nevertheless overactive in many runners with underactive and weak pelvic stabilizers and hip extensors.

I would suggest having your gait analyzed--but keep in mind that not everyone that offers gait analysis knows what they are looking at. In lieu of that I would begin a regimen that focuses on hip and trunk strengthening, using a full-length mirror to monitor your posture. Include single-leg stands, single-leg squats both in the sagittal plane and transversing it in a rotating motion, and prone leg extensions for the hip and lower back stabilizers. (The sagittal plane is an imaginary line running from the front to the back of the body that divides the right side from the left.)

Additionally, single-leg stands with opposite leg abduction (movement away from the body) are excellent for strengthening the pelvis. This exercise targets the gluteus medius, a stabilizing muscle that is notoriously weak in runners and leads to hamstring overuse. While running, concentrate on keeping a long, tall torso with your weight centered over your foot in the stance phase. Focus on pushing off from your hip. Skipping is a good drill for this: Try skipping for 10 to 20 meters, then striding for 50 to 80 meters.

John Cianca, MD

Houston, TX

Pool workouts with a kick board can be effective endurance builders for your hamstrings, quadriceps, and gluteus muscles. Start with five to ten laps three times a week; add two laps per week until you've reached 20 laps. Bike workouts with clip-on pedals will allow you to pull through the bottom of your stroke, which works the hamstrings. Start with five to ten minutes three times a week, adding two minutes per week until you're up to one hour. Also, anaerobic strength training on machines that work your pelvis, core, quads, and hamstrings should certainly not be ignored. Building bone mineral density at the hip is important for perimenopausal women--remember even active women can be at risk for osteoporosis.

Viviane Ugalde, MD

Reno, NV

In Solving Pain on the Right, Don't Ignore Left Side Pain

I am a 5' 3", 120-lb, 43-year-old female distance runner with five marathons under my belt. I have been running a total of about seven years. I had piriformis syndrome on the left side, but I can live with that. My new problem is pain at the iliac spine on the right side. [Editor's note: the piriformis muscle moves the thigh and helps to extend it. The "iliac" or "inguinal" region refers to the groin.] It hurts to adduct the right leg behind the left. At slow speeds I can run through the pain, but it is too painful if I try to run fast. My x-ray came out negative, and I plan to get an MRI. I am currently training for a marathon and hope to have this resolved soon.

Dawn Heinrich

Wolfeboro, NH

"Piriformis syndrome" means different things to different people, but often means tightness or tenderness in the gluteal/buttock region. In any event, this left-sided pain may well affect your running mechanics, with a magnified effect the farther you run. The pain on the right side may be related to the pain on the left side. Treating your piriformis syndrome on the left is part of the means to resolving the pain on the right side.

An examination by a sports medicine physician (if not already done) will help reveal any imbalances in strength and flexibility involving (but not limited to) your hip girdle/pelvic region, as well as any structural (actual) or functional (e.g., due to overpronation) leg length discrepancy.

A stress fracture is surely on the list of possible causes for your right-sided symptoms. You are right to undergo an MRI scan of the pelvis (looking at both the right and left sides), and also a bone scan, as these will more definitely evaluate for this possible diagnosis. Additionally, the possibility that your symptoms on both sides may emanate from a lumbar spine problem should be explored; your physician may therefore wish to perform an MRI scan of your lower back.

As opposed to a stress fracture, spinal disc protrusion or arthritis, a "soft tissue" basis for these symptoms may include a pelvic girdle strain or abdominal muscle on the right side. Relevant strength and flexibility exercises, soft tissue mobilization by a massage therapist, correction of any underlying biomechanical issues (e.g., overpronation, running posture, etc.), and even consideration of running surface and shoes may all be elements of an effective treatment program for both your right- and left-sided symptoms.

In the meantime, until you are running at the level you desire, crosstraining is certainly appropriate to help you maintain your cardiovascular fitness.

Brian L. Bowyer, MD

Columbus, OH

Mysterious Muscle Cramps

I am 55 years old, male, averaging 27 miles per week over the last 10 years. Over the last four years, I have experienced muscle cramping in various muscles from my pelvis to my ankles. They occur mysteriously, and sometimes last weeks or even months, preventing me from running until they subside. I stretch before and especially after running, but I have noticed that my calf muscles tighten up while sitting. I have seen physical therapists and physicians over the last four years, but the cause of this cramping remains unknown. My blood work is normal, including blood count, metabolic profile, and thyroid testing. Should I take potassium supplements or quinine?

Frank Gebraigh

Pittsburgh, PA

If your potassium is not low or at the very least on the low end of the normal range, it is probably not advisable to just begin taking it supplementally. A tendency toward cramping can have many causes. Sodium loss through sweating tends to be the more common source of cramping in many athletes. If you are on a low sodium diet and/or your sodium was low or at the low end of normal, you may need to increase your intake. If dehydration is playing a role, you may need to increase your fluid intake. Drinking a sports drink (which contains electrolytes) can help you achieve both. If you're taking a diuretic medication (e.g., one that treats hypertension), this may be an additional factor contributing to the cramping.

I assume your blood and thyroid tests have revealed no kidney or liver disease. Likewise, cramping associated with a low calcium level is not likely the case if your calcium was in the normal range. Other causes to consider include disorders involving muscle tissue and/or the central and peripheral nervous system, and poor blood circulation to your legs (very unusual in a runner). A physical exam will help you determine whether you should consult a neurologist or a vascular specialist.

While determining the cause of your cramps is advisable, in the short term quinine may provide some degree of relief. Quinine sulfate is now only available by prescription. It ceased to be made available over the counter in 1995 when the potential for (very rare) adverse effects were reported. Quinine in the form of tonic water may be worth a try. Supplemental vitamin E has also been suggested as a treatment, but its effectiveness is controversial; a daily dose of 400IU should probably not be exceeded. Some epilepsy medications can be prescribed to treat cramps, but these tend to have significant potential for side effects.

Brian L. Bowyer, MD

Columbus, OH

After a Stroke, Blood Flow Problems?

I am a 44-year-old brain stem stroke survivor, very fit before my illness. Most of my deficits are involuntary (such as balance problems), and not muscle-control related. I am running again but at about 45 minutes into the run, I experience cramping in my left foot and lose control of my left ankle and foot. Is this what is known as spasticity? Is there anything I can do to reduce this? I'd like to be able to run longer, and I certainly can't see myself giving up running.

Jay Smith

Annapolis, MD

Muscle spasticity during exercise is not uncommon in your situation, and may represent blood flow problems triggered by the running. Most neurologists would probably caution you about running, which is vigorous exercise, but as a runner I appreciate your addiction. Before asking you to abandon the exercise, I advise you to take a treadmill stress test--not to evaluate your heart, but your blood pressure, during running. If it is aberrant, taking an appropriate medication might spare you complications and be helpful to alleviate your symptoms.

Ron Lawrence, MD

Santa Barbara, CA