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The clinic: scarring means little muscle regrowth.

After a hamstring tear playing softball I had discomfort for about three years, during which I had to give up competitive racing. For the past several years, I've been racewalking. It's now been seven total years since the hamstring tear, and I'd like to once again try road racing, but I really want to do it competitively if I do it at all.

I have a large collagen lump in the hamstring--it's about the size of a handball--and the sports medicine doctor I went to said I should not expect the hamstring to regain more than 80% of its prior function. Have there been any techniques developed that might help reduce the size of the lump and make room for muscle regrowth?

Corey Pinkerton

Seattle, WA

Without knowing whether this was a partial or complete tear, and which of the three muscles you tore, I will try to answer. The bad news is that there are no new techniques to reduce the scar tissue. The good news is that there are techniques that have been around for quite a while that will do you a world of good. Unfortunately, the PTs that actually practice them are a bit few and far between.

By using a combo of ultrasound, soft tissue manipulation, and very specific therapeutic stretching and strengthening, the adhesions can be broken. The scar tissue will then be remodeled in such a way as to minimize the negative effects on muscle tissue. By manipulating the fibers as they redeposit, the scar will be stronger and will act and feel more like "normal" tissue. The challenge will be to find an orthopedic manual physical therapist who will do the work--and it does take work. Passive modalities without the manipulation will yield little in the way of results.

Maribeth Salge, PT, CSCS

Rockledge, FL

This is a difficult problem to treat. The lump that you feel in your hamstring is probably the remnant of a partial tear that you incurred. It is probably made up of dense, fibrous scar tissue. It is unlikely to be affected much by massage, injection, or even surgery, and unfortunately at this point there will not be any muscle regrowth.

I would suggest exercising to your pain tolerance. Or course you should commence with a gentle warm up that includes stretching. Doing some light massage on your own after workouts will also be beneficial. I would try non-impact activity as well, such as pool running with an aqua jogger, or using an elliptical trainer in the gym. You may be able to run again, but as you said, it may not be at a very fast pace!

Jon Halperin, MD

La Mesa, CA

The lump in your leg is quite likely the remnants of your hamstring that have balled up in your leg. It is not going to heal and there is not going to be any muscle regeneration at this point. If you want to confirm my suspicions, an MRI or diagnostic ultrasound exam would be helpful. It is probably likely that you won't have full strength in your hamstring but you still might be able to run/race--albeit not at your previous capacity.

John Cianca, MD

Houston, TX

Is Nagging ITB Really a Cartilage Tear?

For the past two years, I have had iliotibial band (ITB) syndrome in my left knee. It originally occurred when I was training for my first marathon. After completing that marathon and one other, my knee pain went away after several weeks off from running. It reemerged six months later during training for my third marathon, even though I was very careful to increase my mileage slowly and methodically. Any time I ran longer than 10 miles, I had pain on the outside of my knee. I completed the marathon anyway and then another marathon a month later. Although I have now taken four months off from running, I still occasionally feel knee pain when walking considerable distances. I have followed various stretching and strengthening programs without success. I don't want to begin running until I am pain-free, but I am eager to get back out on the roads. Do you have any suggestions for treating this type of chronic injury? Would surgery be an option?

Philip Henckel

Carthage, GA

Surgery is not something to consider for this type of problem. ITB syndrome can be chronic and annoying, but it is certainly something that can be managed. If you see a physical therapist, there are a variety of effective treatments that may help you. Cross-friction massage is a deep massage performed perpendicular to the fibers that are causing you trouble. It is painful, but very effective for treating ITB syndrome. Also effective for ITB syndrome are iontophoresis treatments which use special equipment to electronically deliver dexamethasone into the skin at the point of inflammation and ultrasound treatments. With any of these treatments, you need to stretch regularly. Unfortunately, many runners only stretch on days they run, but they should really do so daily.

Ron Kleinman, PT

Akron, OH

I feel you need to look in another direction regarding your knee pain. You seem to have given the knee an appropriate amount of rest with minimal to no results. At this point, you need to make sure that you are not dealing with another condition, such as a chronic meniscal (cartilage) tear, a sprained lateral collateral ligament (LCL), or lateral chondromalacia (a softening of the cartilage). All of these conditions can be revealed through MRI. You also need to make sure that your running mechanics and foot posture are correct. A sports medicine podiatrist or physical therapist would be able to do an evaluation for you.

Brian A. Magna, MA, PT

Avon, CT

Advice for Stalled Weight Loss

I'm a vegetarian who runs daily and stays active with crosstraining like biking and kayaking. For some reason, I find it impossible to dump a couple of extra pounds from my body weight unless I starve myself, which seems counterproductive. The extra pounds mean that my race results are not where they were and I'm very upset about it. I'm 55, female, and can't really exercise any more than I already do. Nor do I think I can eat less. What to do?

Sue Spacey

Denver, CO

I agree that it's counterproductive to starve yourself. You may be able to make some changes that will enable you to eat fewer calories without feeling as if you are starving. One concept that is important to keep in mind is the idea of energy balance. As you probably are aware, your body expends energy every day whether you sit at a desk, walk, run, bike, or swim. Every time you eat, you take in energy. If weight loss is your goal, you either need to increase your activity so that you expend more energy, take in fewer calories, or do both.

If you have a few extra pounds to lose, it may be helpful to write down everything that you eat (food or beverage and amount) for at least three days. Then, evaluate your eating habits. Were there "empty calorie" foods that made little contribution to your diet other than providing calories? Eliminating these or cutting down on them can help with weight loss. Pay special attention to portion sizes. If you eat out often, it's very easy to eat more than you realize.

As you embark on a weight loss plan, it's important to clearly establish your weight goals. There are numerous BMI calculators online to determine what an appropriate goal weight would be for you. Also, devices like Fitbit and smart phone apps that track nutrition and activity can help you strike the energy balance most desirable for shedding pounds.

A safe weight loss rate is one to three pounds of weight per week. By looking at your weight goals and a reasonable weight loss rate, you can see about how long it will take to lose the amount of weight that you want to lose.

Here are a few other food-related suggestions:

Be sure to eat generous amounts of higher fiber foods like fresh fruits and salads. Eaten before a meal, these foods can make you feel full so that you're less tempted to overeat.

Try not to skip meals. Sometimes when people skip meals, they end up eating more at their one large meal than they would have eaten at three smaller meals.

Practice mindful eating. Ask yourself if you're hungry or if you're eating for another reason like fatigue or boredom.

Activity is the other side of the energy balance equation. You mentioned that you didn't think that you could exercise any more than you already do. It's great that you are running, biking, and kayaking! While it may not be possible to exercise any more than you do, you may be able to find ways to increase your activity in general. As you go about your daily routine, think about times where you could walk instead of drive, take the stairs instead of the elevator, and/or get up and move around for five minutes every hour if you have a sedentary job. These small increases in activity, along with a moderate reduction in energy intake, should lead to the weight loss you'd like to see.

Reed Mangels, PhD, RD

Amherst, MA

Puzzling Incidents of DVT

A male client of mine, in his mid-40s, is a distance cyclist who has developed his second DVT in three years. Why would a young healthy male develop clots?

Laura Stadtmuelle

Middle Village, NY

I discussed this issue with one of my co-workers, who is a specialist in blood clotting disorders and a fellow runner, and have incorporated his comments into my response.

There are several reasons why people form DVTs. There are a number of clinical entities associated with increased risk of forming a blood clot, including recent surgery, prolonged immobilization such as a long airplane flight, certain medications, and the presence of other diseases such as some types of cancer or kidney disease. In the vast majority of cases these entities associated with increased risk of clotting are readily apparent and provide an explanation as to why the DVT formed.

There is some controversy as to whether severe and prolonged exercise by itself can be associated with DVT. Some studies suggest that acute severe exercise increases the tendency for blood clotting, although chronic exercise training may lower this risk. There are anecdotal reports of marathon runners being diagnosed with a blood clot shortly after running a marathon, and some authors have speculated that dehydration may play a role, but these observations remain primarily anecdotal.

Some otherwise healthy adults who form DVT may have an abnormal antibody in their bloodstream that predisposes toward clotting (e.g., the lupus anticoagulant/antiphospholipid antibody). Some may have a deficiency or abnormality of a protein that participates in the body's clotting/clot-inhibiting systems. These protein deficiencies/abnormalities are genetic and include entities such as antithrombin deficiency, protein C deficiency, protein S deficiency, Factor V Leiden mutation, prothrombin 20210, and dysfibrinogenemia, among others.

There are laboratory tests to screen for these genetic abnormalities. These tests are expensive. Performing these tests in your client's situation could be helpful for addressing why he has developed DVTs but would unlikely lead to later treatment recommendations. Most authorities would argue that since your client has had a second DVT, he should be treated with life-long Coumadin therapy (unless there is a contraindication), regardless of what the tests indicate. Since the protein deficiencies/abnormalities are genetic, the presence of one of these disorders does have implications for passing on this abnormality to one's offspring, and testing could be important for this reason.

Todd Miller, MD

Rochester, MN
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Publication:Running & FitNews
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Date:Mar 1, 2013
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