Author Archives: John Post

About John Post

Othopedic Surgeon 6 Kona finishes Married, 3 children Marine Veteran Helicopter Pilot

Triathlete With Enlarged Heart – Abnormal?

Triathlete with Enlarged Heart – Abnormal?


“The heart is the first feature of working minds.”
                                                                       Frank Lloyd Wright
We see frequent headlines noting the very premature death of young athletes with pathologic cardiac conditions, the so-called enlarged heart also known as hypertrophic or dilated cardiomyopathy. It’s been proposed that athletes participating in multiple endurance events like iron distance racing or a high number of marathons induce subtle changes, which, over time, can lead to significant changes in cardiac function. Negative changes!
To answer this question, researchers tested Olympic level athletes using EKGs, echocardiograms, etc., over a 9 year period and found little correlation to the extremes of training intensities/volumes to any cardiac difficulties.
In the article by Levine, et al, they summarize these findings stating, “…the report goes a long way to reassure the medical community of the inherently physiologic and clinically benign nature of prolonged and intense endurance training.”

So, when we see high profile athletes like Ironman Hawaii Champion Greg Welch with well publicized heart problems, don’t blame the training per se but look for a different explanation. Keep up your own training. But/if you have anything like chest pain, jaw pain, etc., don’t just blow it off, ask someone who knows. Better safe than sorry.
Shoulder Pain, the A, B, C’s/Choosing a Sports Doc

Golfer’s (Swimmer’s) Elbow by John Post, MD

These guys have no elbows. For the inaugural Ironman race on Oahu in 1978, Navy Commander John Collins made the winners trophy in his basement. It became known as the “Hole in the Head” for a couple obvious reasons, among them it’s appearance and, perhaps describing anyone who’d do the 140.6 miles! 8″ miniatures were given to each finisher of the 25th Anniversary Ironman in 2003. A cool thing to do for sure.

I was recently asked about tendinitis over the inside or medial aspect of the elbow. In Orthopedic circles this is known as Golfer’s (swimmer’s)Elbow.

Golfers elbow – or medial epicondylitis – is pain at/near the muscle origin over the inside of the elbow. Sort of like tennis elbow but on the opposite side of the elbow and less frequent. It seems to occur in men more than women, dominant over non-dominant arm. Although pain is the predominant complaint, people will sometimes note forearm or hand weakness, numbness radiating into the hand, usually little finger and ring like when you hit your funny bone. I’ve had some folks complain of a just plain stiff elbow.

You’d like to know why you “got” it. Was it overuse or repetition of placing the elbow in an overloaded state or was it a single forceful episode that over taxed the muscular origin? The diagnosis is usually made by your story and findings on physical exam. Often x-rays are obtained to look for arthritis, missed trauma, etc. Very rarely will someone think about an MRI.

In any event, the right things to start with include strapping, NSAIDs, etc. I’ve had very good success with PT/Occupational Therapists who’ve gotten the patient to be absolutely anal about stretching and icing among other things.

Failure of the above, in my office, gets a corticosteroid injection as they just seem to work. Maybe even two, over time. Here the literature gets a little cloudy. As has been noted here before, Orthopedic Surgeons (and I’m one of them) are quick to jump on a passing bandwagon. PRP is basically your own blood placed in a centrifuge. The clear part, or plasma, is where this high concentration of platelets is extracted and subsequently injected in the area of chronic tendinopathy. It makes sense. But it’s still new enough that there are few long term studies on which we can base treatment on science, not intuition. A NY Times editorial earlier this year quoted two studies where it had been injected in elbows – one helped more than standard treatment, one didn’t. Also, and this is important, many insurers will not pay for it. And it can get right expensive! So, the jury is still out on PRP but I think, ultimately it will have a role. But not as first line treatment. We just don’t know what that role is. Yet.

Very occasionally a surgical procedure will be needed but in most people’s hands, only after failure of an extensive conservative effort.

Ever Been Stung By A Jellyfish? by John Post, MD

 

“The guy sure looks like plant food to me.” Audrey II, Little Shop of Horrors

Many of us have run into a jellyfish or two either training or racing in ocean water. More of an inconvenience than anything for most of us, some poor souls have a more significant reaction. I answered a questioner this week who stated a jellyfish sting allergy and she wondered about the legality of wetsuits in an important ocean swim she has in her future, I suppose thinking the wet suit a shield of sorts.

Well, her race is Ironman Hawaii where wetsuits are not permitted. I’ve been stung in Kailua Bay a number of times, but it’s always more like little needles that hurt/itch a little that day and then, like most of us anyway, it’s gone. I’ve never even seen the ones that got me. If you’re lucky, and looking ahead while you swim, which I know most of us don’t do, and there’s a big Portuguese man-o-war ahead, you can try and swim around it. Remember, it’s tentacles can be 5-8 feet in length and have 100’s of stinging cells on each. It’s not uncommon after a stinging that some swimmers experience nausea, headache, muscle pain, etc., and after the initial welts subside they’re left with permanent scars.

In some locations, primarily around Australia, some jellyfish stings are so powerful that those who encounter them may need hospitalization with intravenous anti venom without which they suffer respiratory failure and and die quickly.

So, if this summer you are stung by one, first (with gloves) peel off any left over tentacles and apply vinegar, straight from the kitchen. More involved stings may require medical attention and support from a cardiopulmonary perspective. And, always be aware of the signs of an allergic reaction – difficulty swallowing/breathing/swelling, etc.

And how do we advise our lady with jellyfish allergy? Well, first, I told her to contact the race director and race medical team well before the event. They need to know of the possibilities here. Second, there’s a high likelihood that she can be “premedicated” before the race such that should a stinging event occur that she’s covered. Sadly, in this day and age, I wouldn’t be surprised if a special document isn’t drawn up for her signature noting the risks she faces and accepts. Hey, it’s 2012.

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Reduce Your Fracture Risk, Take Vitamin “D” Daily

For Those Who Are Always Injured or Can’t Run

Confidence in Triathlon Swimming by John Post, MD

Through early morning fog I see,visions of the things to be… Johnnie Mandel, Suicide is Painless, M.A.S.H.

This week, as we prepare for the 2012 racing season , I’ll bypass the injury pipeline and pass on a little experience. After making many mistakes over the years, I can reveal the secrets to not only your fastest safe swim but how to be equipped for those unexpected problems that can throw a wrench into your whole day.

In other words, this is why I keep a spare pair of goggles in my suit. You must think of things that can go wrong, and have a solution in mind, well in advance of the race. Let’s divide these into:

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Achilles Tendon Ruptures 2012 by John Post, MD

Achilles Tendon Ruptures 

“What we have here is a failure to communicate.” Cool Hand Luke

Last month I published a piece entitled “What a Triathlete Needs to Know About Antibiotics” that was well received. (Thanks) The impetus of that post was a series of confusing ST threads concerning the potential side effects of certain antibiotics, especially fluoroquinolones (Levaquin, Cipro, Avelox, etc.) It was intended to clear up misconceptions as to the relative frequency of these side effects, most noteworthy rupture of the Achilles tendon. (Note: at a Primary Care review course I taught in Florida this week to > 200 physicians, when asked, only 2 docs admitted to personally experiencing this complication in their practice.)

The Achilles tendon is the strongest, thickest tendon in the body connecting the soleus and gastrocnemius to the heel. Men in their 30’s and 40’s seem to have the highest rupture rate, particularly those who are active in sports, especially the weekend warrior who’s relatively sedentary during the work week but really goes at on Saturday . Many in medicine feel that it’s a previously abnormal tendon that ruptures. Although it can fail both at the mid calf level, the junction between the muscle and tendon, or closer to the insertion in the heel, the latter is more common. The tear itself is usually ragged and irregular and not so easy to repair. The diagnosis is made on physical exam by palpating a space where the Achilles normally resides and a positive Thompson test, squeezing of the calf of the prone patient noting whether or not the ankle flexes. In a failed tendon, the ankle will not flex. Most often, there is little or no warning that the tendon will yield.

When diagnosed acutely, options include operative or non-operative treatment, most often the younger population choosing surgery. This could be either a traditional open operation or a per cutaneous procedure. That said, there is an increased risk of complication (infection, adhesions, etc.) over those who’ve chosen the non-surgical route but a lower incidence of re-rupture. Following the operation, most patients will be placed in a cast or splint short term followed by a functional brace. Return to sport varies depending on the solidity of the repair, post-op pain, and ability to prevent re-injury.

Since our goal is to prevent injury in the first place, correction of limb length inequality, arch problems, bio mechanical issues, etc. all help in attaining this. Although there is some controversy, lightly warming up, stretching – both straight legged and bent kneed – perhaps even with a little light massage, coupled with a general fitness program seems to be our best protection in keeping the surgeon at bay.


Super Ironman Hawaii volunteer,Mike McCurdy

Quick Note: with the arrival of warmer temps and daylight savings time, many of us are out on the roads earlier, later and longer. Of the four strobe lights on biker’s butts on this Sunday’s ride, all four needed new batteries. One was so bad you could hardly see it in the pre-dawn darkness…drafting! So, before you ride again, change all those batteries and be safe.

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Notes From A Pregnant Athlete

REAP BENEFITS OF AN EFFICIENT RUNNING STRIDE by John Post, MD



A participant in the Underpants Run. A counter-culture event run in Hawaii two days before the Ironman where proceeds go to support a local charity. And yes, the shorts are bogus. Make sure you look at the rest of the runners.

Quick Note: with the arrival of warmer temps and daylight savings time. many of us are out on the roads earlier, later and longer. Of the four strobe lights on biker’s butts on this Sunday’s ride, all four needed new batteries. One was so bad you could hardly see it in the pre-dawn darkness…drafting! So, before you ride again, change all those batteries and be safe.

We tend to get complacent. To assume that because we have a great deal of experience doing something that we remain proficient at it. This is a major contributor to running injuries and a reason for people getting injured in a traffic accidents. Let’s try to reverse that. There’s already enough controversy in running equipment now…Newtons, Vibram, etc., that if we stick to what we know we’ll stay out of trouble. Let’s try to review the running stride and how to do our part to remain injury free.

Ben Greenfield preaches frequently regarding stride frequency. He feels that many of us over stride and this leads to higher loading of the lower extremity than is required for the given pace. He has his athletes take 22 strides per 15 seconds to minimize the impact seen by the limb. According to experienced defense lawyers in Rosemead, diminishing leg stress is obviously beneficial and not only might it give you a more compact running style, and help load the leg evenly decreasing injury, it might even contribute to a longer running career. If the lug injury is caused in an accident, then you can get traffic accident claims with the help of reliable lawyers. How many ex-runners do you know, out not because they’re tired of it, but because they can not stay injury free? Look at the race results of your local tri and compare the number of competitors in the 30-35 year old ager group to those of 60-65.

Mark Lorenzoni, owner of our local running shoe store, a man I’ve quoted here before, has over 25 years of caring for runners, and preaches the same thing. He wants his runners to count 30 strides per 20 seconds. He suggests they give themselves a “pop quiz” in the middle of the run after they’ve warmed up by counting the number of left foot strikes for 20 secs and checking to make sure it’s 29-30, regardless of pace. He’s convinced that the incidence of IT band problems and plantar faciitis is lower in athletes who do this.

He also is a big supporter of mid-foot strikers and tells clients to pretend they have a pebble under the heel of their shoe and they’re trying not to put too much weight on it at foot strike.

The take home point here is to have someone knowledgeable evaluate your stride at regular intervals and see if you’re as good as you think you are.


Can you identify the athlete on the left with the American Interbanc shirt just before the Underpants run start?

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Top Ten Mistakes in Your First Race of  The Season

Back Pain in Triathletes

SICKNESS/INJURY CAN BE A GOOD THING by John Post, MD

Sickness/Injury Can Be a Good Thing


“Something’s happening here. What it is ain’t exactly clear.” Buffalo Springfield

Triathletes are generally control freaks. Schedule, time, work outs, you name it and they have a very specific time and place for it in their life. One of my best tri buddies used to have such a stranglehold on his schedule that he’d leap out of bed at 2:30 a.m. to start his training day! But what happens when one is injured and forced to alter the grand plan? Or worse, when you’re sick and can neither work nor work out? (Get out the Valium???)

I like to look at it as opportunity knocking. Like taking that 10 hour drive by yourself, and, when you become tired of the music, you roll along quietly, your mind drifting from topic to topic and voila, you come up with the solution to a problem that had previously escaped you.

It’s at times like these when we frequently have a clearer view of options available to us, to alter habits or patterns that are less than ideal, limiters so to speak. It could be to stop smoking or perhaps realign dietary habits. Something personal and something physical. After all, we are triathletes aren’t we? Sort of like a mini New Years resolution. You might think twice about pounding down that whole tube of Girl Scout cookies. (Although those thin mints are tough to put down when you’ve only had a couple.) I have a riding mate that used to imbibe his share – some would say more than his share – of booze, and it was during an illness where food was the last thing on his mind, that alcohol also took a back seat. He drinks very little now.

Thus, it would seem the take home lesson here is to find opportunity where others would not. Truly, you’re making the best out of a bad situation.

Does this look like the swim start of the famed Ironman Triathlon World Championship in Kailua-Kona, Hawaii? It is. It’s just missing a few athletes!

*The smoking donkey store front is on Alii Dr, Kailua-Kona, HI

YOU CAN’T ARRIVE AT THE RACE SITE TOO EARLY by John Post, MD

You Can’t Arrive At The Race Site Too Early

Racking one’s bike very carefully. It has a big job in just a short while.

In my mind, you’re never early on race day. Maybe late, but never too early. You can’t put a price on being as relaxed and in control as much as possible when the gun for your swim wave goes off.

As you get more experienced, your habits become more efficient, transition set up is more easily accomplished and you have more time to scout out the area. If you don’t have the quickest transitions in your age group, WHY NOT? And who does? You can literally shave minutes from your time. In my most recent race, the shortest total transition time – T1 plus T2 – was 2:30 (guess who), and the longest 5:59. That’s 3 and a half needless minutes, an eternity when checking the race results after you’ve crossed the line! Next week I’ll blog only about transitions, but you get the point. An early arrival allows for an adequate warm up in each of the disciplines without the feeling that you’re hurrying. In my mind, particularly if you are an older athlete, this is the opportunity to really loosen up the shoulders and legs. Not only does your potential for an outstanding performance increase, the probability of injury diminishes…the common thread of this web site. Not everyone agrees with this concept. In Kona, the gun for the pros is 6:30 am, and age groupers 7:00. But, if everyone looks set, the starter can release the age groupers as early as 6:55 am. Believe it or not, in what might be the most important athletic event of their lives, at 6:50 there are still people in the transition futzing around with their tires, or helmet straps, what have you. They’ve had months to get this done and this lack of preparedness will put them late in the water, late to the start, and perhaps spoil a major portion of the day.

I have also used this pre-race time to learn. To learn from the other participants as I appear casual in my inspection of their gear and transition area. As you might expect, those in age groups far different than mine are most eager to help. Those in my age group…less so (ahem).

Lastly, today would you rather eat or work out? If you said work out, that’s the right answer. You can always eat. I was recently told that French children learn from an early age that, for them anyway, meals are multi course and paced. There’s even a cheese course. That’s true for us on occasion, but if you can get in a 4 mile run over lunch with a 3 minute shower, or maybe even just wipes, your log book will be smiling when you get home. And don’t we all like happy log books?

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Tsunami Hits Kona 2011, 1 Year Later

ANTIBIOTICS FOR TRIATHLETES – TENDON PROBLEMS by John Post, MD

Antibiotics for Triathletes – Tendon Problems?

Several athletes have questioned the use of antibiotics lately, especially as it relates to potential complications. For this piece I interviewed pharmacists at: 1) my hospital, 2) a private drug store in the area, 3) a national chain drug store, 4) The PharmD Drug Information office at a nearby large hospital, 4) The Physician’s Desk Reference (very big book), etc. to try to give the most well thought out answer.  This is a distillation of what I presented on Slowtwitch.com.

Before the discussion, however, we must continually remind ourselves that the days of simply going to the doctor with a problem and expecting to “Get something for it” are gone. Long gone. We as consumers are expected to understand that there are both viral and bacterial origins for a host of infections processes and that antibiotics are ineffective in cases of viral illness. The doctor is expected to know the difference. That said, on more than one occasion, I am quite guilty of giving out a prescription when I was certain that the patients problem was viral. It’s what they expected and, particularly when working the ER, was the path of least resistance.

Depending on your source, the 5 most commonly prescribed antibiotics are Amoxicillin, Augmentin, Penicillin, Zithromycin and either Cipro or Levaquin (also known as ciprofloxacin and levofloxacin). Most of the questions have centered around the last two, members of a family of drugs called fluoroquinolones. This class of broad spectrum antibiotics has been around since WWII coming originally from a drug used in malaria called Chloroquine.

So, your physician had determined that you have a bacterial infection and needs to choose the “best” form of treatment. But the specific antibiotic chosen is a complex process taking into account the specifics of the patient and the illness, the cost of the different drugs, the insurance coverage and what out of pocket expenses will be, the dosing schedule (once a day, four times a day, etc.) and the likelihood the patient will adhere it, and…oh yeah, potential side effects. In the case of the fluoroquinolones, the potential for tendon problems is noted by the manufacturer as “Ruptures of shoulder, hand, Achilles tendon or other tendons that required surgical repair or resulted in prolonged disability have been reported…..(this risk is increased in patients taking steroids, especially the elderly.)” But simply watch any evening news TV drug ad, say for Viagra, and they quote a list as long as your arm of potential problems. I’ve heard that after the third one your brain shuts off. Has it stopped people from taking Viagra?

If you go to the Peoples Pharmacy web site, there are over 100 posts from folks who report a host of problems which they attribute to Levaquin. But if you look at both the significant good that these drugs do and the enormous number of prescriptions written, the incidence of tendon concerns is pretty darn low. In fact, on Slowtwitch, Dr. Rod Roof noted that “The Achilles tendon is a bit overblown (based on the number of tendon issues vs. total prescriptions that is)” and a number of physician triathlete posters have both prescribed and personally used these medications without a downside.

Triathlete take home. Print this and save it somewhere. Next time your doc recommends an antibiotic for your bacterial infection, talk to him/her about it, particularly your knowledge and concerns. And, if after reading this you feel you’d like to stay away from this class of drugs until other options have been exhausted, say so. If you do end up on one, it would seem prudent to first ensure you’re not taking a corticosteroid like Prednisone, and to back off the training for a while. In the unlikely event you should experience tendon difficulties, stop the drug and call your doctor. But, again, the incidence seems pretty low and if it were me, this is the thought process I’d use and take the drug.

John Post, MD
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Distracted Driving, Cyclist Killed, Pass It On

DOG BITES BIKER, BOTH SURVIVE by John Post, MD

Dog Bites Man, Both Survive


The sword of time will pierce our skins, it doesn’t hurt when it begins. Johnny Mandel, Suicide is Painless

I’m a slower biker than I used to be. Or maybe the dogs have gotten faster. Either way, a dogs teeth “pierced my skin” last year while I was cycling a few miles north of town. I stopped, went to the owner’s house and reported it. Surprisingly, he offered no apology, no help, no phone call, no nothing. He just said,”I’ll take care of it.” Well, that’s not good enough. I told him I’d notify animal control as soon as I got home. He was not happy and made that very clear.

Actually, I pedalled out of sight of the house…and dog…stopped, cleansed the bite with everything that was in my water bottle. I tried to remove as much of the dog’s saliva as possible. As soon as I was back in cell phone range, I called my wife, gave her the facts and the house
address in case the headlines in the next day’s paper included “Biker shot north of town”(The dogs owner made out like it was the biker’s fault) she’d know where to start the search.

Then it was a short ride to my doctors office where the wound was cleaned and disinfected, tetanus booster administered, and phone call made to animal control. Although you’re concerned about infection, rabies, although unlikely, is more of a concern. I had a bat land on my head once while running – I know – a what? Although I felt the sharp claws as it landed on my skull cap, the skin wasn’t broken and I wasn’t bitten. They are known rabies carriers. The difference here is that with the dog, it can be observed for any signs of illness, it’s inoculation status is known, as is it’s physical location. None are true with the bat.

We’ve been vaccinating dogs in this country for over seventy years and this has reduced the documented cases of rabies to less than 5 annually. Internationally, however, upwards of 50,000 deaths occur each year, probably more. In the U.S. when we think rabies we think skunks, raccoons, foxes, and as mentioned, bats. A bat’s bite can be missed, particularly by children. If one is found in the home,particularly with access to sleeping children, it should caught for later examination.

In short, although dogs chase us repeatedly, and there are some roads we avoid simply due to canine presence. Should you be bitten:

1) Identify the animal and inform local animal control
2) Cleanse the wound as best you can immediately
3) Seek medical care

As mentioned, very few die from this disease. But if you need the post-exposure rabies prophylaxis (series of shots), they are neither painless nor cheap. In other words, forget about those new aero wheels!

John Post, MD
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“Your Medical Help at the Races”