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Q. Is It Runner's Anemia?

I am 49 years old and have been running for three years. My race times have been improving (43:15 to 38:30 for 10K). I am concerned that since I began running, my hematocrit has decreased from 43.6 to 37.7 and hemoglobin from 15.3 to 13.2. I feel fine. My resting pulse is 44 and I am not fatigued. While I realize that I may not be anemic in a "textbook" sense, I am concerned that these low values may limit my running performance. I have tried taking an iron supplement (27mg ferrous fumarate) with no effect. Should I have any other tests? Should I worry about these changes?

Bob Meixner

Hinsdale, IL

A. Runners have three main reasons for low hemoglobin concentration: dilutional pseudoanemia, iron deficiency, and footstrike hemolysis. To understand the anemia and your lab tests, we need to understand the terms used when describing anemia.

Hemoglobin is a protein-iron compound that carries oxygen and is located in red blood cells. Hematocrit is the percentage of red blood cells by volume in a blood sample. Ferritin is an iron-protein compound that stores iron not used by the cells. A low ferritin is an accurate predictor of low body iron.

True anemia is a condition where the number of red blood cells, the amount of hemoglobin, and the hematocrit are low. Endurance athletes normally have a slightly lower hemoglobin concentration than sedentary people. Athletes have lower hemoglobin because plasma volume (fluid in the circulation) is increased by exercise. This is a normal adaptation to exercise and not a true anemia. The red blood cell number is not reduced. This adaptation actually improves athletic performance by increasing the volume of blood pumped with each heartbeat, improves efficiency of sweating, and delays dehydration. The degree of dilutional pseudoanemia roughly correlates to the amount of exercise.

In the case of true anemia, the number of red blood cells is decreased. Comparingblood values before athletic training in an endurance athlete, a drop of one gram per deciliter of hemoglobin is probably dilutional. One to two grams per deciliter is possibly significant and more than two grams per deciliter is very suspicious for true anemia. Hemoglobin levels in male athletes are commonly below 14 grams per deciliter, rarely under 13 and almost never under 12. For females, the values would be lower by one to two grams per deciliter. Your values fall within the range expected in dilutional anemia

Iron deficiency is one type of anemia. A low ferritin, a low hemoglobin, a low red blood cell number, and a low mean corpuscular volume (MCV) support the diagnosis. MCV is a measure of the red blood cell size, which is generally low in iron deficiency anemia. Although controversial, low iron level without anemia probably does not decrease performance. Normal endurance runners can lose small amounts of iron through sweat, the gastrointestinal tract, and urine. Significant losses may occur though the gastrointestinal tract because of aspirin and other anti-inflammatory medications. Women may lose significant amounts through menstrual bleeding. Vegetarians have low iron absorption compared to meat eaters, because the iron in vegetables and grains is harder to absorb than that in meat. However, athletes as a group probably have ferritin levels similar to those of non-athletes, and probably don't lose more iron than non-athletes.

Footstrike anemia is caused by vascular and red blood cell trauma in the feet. It is less common since running shoes have improved. This form of anemia occurs most often in runners 30 to 50 years of age who run 30 to 50 miles or more per week. It occurs more often in heavy runners, with poorly cushioned shoes, who run on hard surfaces, and have a heavy foot strike.

Assuming that you have a dilutional pseudoanemia, this will not adversely affect your performance. It is not necessary to increase your hemoglobin concentration. Your physician can confirm that your hemoglobin level is due to a dilutional adaptation to exercise. True anemia, especially iron deficiency anemia that develops in a male over the age of 40 needs to be investigated carefully to rule Out serious underlying conditions.

Jeffery M. Hubbard, MD.

Clovis, CA

Q. Propecia and Running

I am a 53-year-old male recreational runner (20 to 25 miles per week), I supplement my running with strength training. I would like to try Propecia, the new prescription treatment for male pattern baldness. I understand that this drug has some antiandrogenic effects, at least on hair follicles and the prostate gland. How selective are these effects? Would it have any negative effects on athletic performance? Would it inhibit muscle growth and development in a strength-training program?

Samuel Smith

Springfield, MO

A. You are right about Propecia (finasteride) being an androgen hormone inhibitor. Propecia is the same medication as Proscar, which is used for benign prostatic hypertrophy at the five-milligram strength. The mechanism of action of finasteride is to inhibit the steroid 5-alpha reductase, which is an intracellular enzyme that converts testosterone into the potent androgen 5-alpha dihydrotestosterone (DHT). This enzyme is a Type II isoenzyme and is found primarily in the prostate, seminal vesicles, epididymides and hair follicles as well as the liver, but not the muscle. What this means is that the activity of the finasteride is confined almost exclusively to the target organs and should not affect muscle mass or athletic performance. The anti-androgen action of this medication is confined almost entirely to the scalp and prostate.

Finasteride is generally well tolerated. Adverse reactions usually have been mild and transient. The two most common side effects at the higher dose of five milligrams daily are impotence (3.7%) and decreased libido (3.3%). These side effects have not been reported at the dose used for male pattern balding.

Finasteride will not help you run faster or promote muscle mass, but it also won't inhibit your progress in your training regimen.

David C. Tattan, D.0., C.M.D.

Jamestown, MI

Q. Sodium and Cramps

I'm a 40-year-old middle of the pack runner (20 to 30 miles per week). For the past five years, along with shorter local races I run one marathon a year as an annual fitness goal (PR 3:46). During the spring, summer, and fall months I supplement my running with approximately 50 to 75 miles per week on the road bike.

This year in preparation for my spring marathon, despite more than adequate hydration and pasta loading, I was constantly nagged with cramps in my thighs. They occurred from the inside of my knee up the inside of my thigh on both legs, making it impossible to take another step. This year, for the first time in five years, I was unable to finish my marathon because of these cramps. Help!

Greg Jenkins

Laconia, NH

A. The most likely explanation is that you are suffering from heat cramps. These usually occur in unacclimatized individuals who exercise vigorously in the heat, but may also occur in conditioned athletes. These are characterized by brief, intermittent and often excruciating cramping pain in the muscles that have been subjected to extensive work, such as' the muscles of the thigh during a marathon. Heat cramps are caused by salt depletion with hypotonic (low salt) fluid replacement. You don't mention what you are hydrating yourself with during exercise and marathons. If you are only drinking water it is likely that you are becoming sodium depleted during extensive exercise. To prevent this, liberalize your daily salt intake with food or try drinking a sports drink that contains electrolytes, such as Gatorade, during your exercise training.

Pain in the thighs may represent referred pain from a musculoskeletal problem of another area such as the back. If increasing sodium during endurance exercise doesn't alleviate your leg cramps, I suggest that you see your family physician to have an evaluation of this problem. I hope this helps you continue your running and ends your leg cramping.

Theresa A. Guise, MD.

San Antonio, 2%

A. Vascular problems such as blood vessel blockage can also cause these symptoms. See a sports medicine professional to evaluate the possible sources of your pain.

Lewis G. Maharam, M.D., F.A. C.S.M.

New York, NY

Q. Hip Pain After Long Runs

Since running long runs, I've had a pain in the side. It's on the right hipbone and below it. It hurts after a long run and in the morning. It's bothered me for a couple of weeks now. Coincidentally, my right knee always aches after running long. Pain on my left side is rare and goes away quickly.

Michael T. Moshitta

Monsey, NY

A. Although I would like to know more about your training schedule and the surfaces you run on, a common problem runners experience is the iliotibial band syndrome. The iliotibial band is the tract that runs up the outside of your thigh and attaches to the outside part of your knee. It often develops friction in the lubricating sacs or bursa that allow this tissue to pass over the bony structures of the outside of the knee and also at the hip. A number of different problems can cause these to become irritated and cause pain. Possibilities include a position of slight bow-leggedness at the knee, mild leg length differences, malalignment at the ankles, weak hip abductors (gluteus medius and minimus), training errors such as sudden increases in distance or inadequate warm up. Consistently running on the same side of a cambered road can cause problems, particularly in the leg that's on the sloped side. Running downhill tends to be more painful with iliotibial band syndrome. It is more common in men than women, an d in those who are thin.

There are several ways that you can test for the iliotibial band tightness. if you stand on the affected leg with the knee bent to 30 to 40 degrees this may worsen your pain, as would hopping in this flexed knee position.

Treatment of iliotibial band syndrome includes rest while the problem heals, then gradually increasing activity as long as you are pain free. Avoid hill running until you have had no symptoms for at least four weeks. Anti-inflammatory medicine like Advil or Aleve can be helpful. Massage ice on the painful area to reduce inflammation. Stretching of the iliotibial band is very important. Stand with both feet pointing forward, with the foot of injured leg crossed behind and to the outside of the uninjured foot. Slide your hand down your side toward the knee, bending your trunk directly to the side over your lowering hand.

If your symptoms do not improve within a few weeks, see a sports medicine professional to evaluate your biomechanics. A steroid and local anesthetic injection into an inflamed bursa or area of tendonitis may be helpful. You may also need orthotics to offset biomechanical errors.

Jennifer Finley, MD.

Overland Park, KS

Ask the Clinic!

Are you bothered by an injury? Do you have a training or diet question? if so, ask The Clinic, in care of AR&FA, 4405 East West Highway, Suite 405, Bethesda, MD 20814, FAX (301)913-9520, e-mail Free personalized sports medicine, training, and diet advice is an exclusive benefit for AR&FA and AMAA Members only. AR&FA has more than 255 Clinic Advisors representing more than 27 specialities. Include 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. Handwritten FAXed letters will not be accepted. Include your address and phone number in case the Advisor has additional questions or would like to discuss your case with you. Responses usually take three to four weeks, but can take as long as five.
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Title Annotation:answers to questions about health issues for runners
Publication:Running & FitNews
Date:Feb 1, 1999
Previous Article:Deciphering knee pain.
Next Article:What's next after the big race.

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