Ask the experts: Fitness loss, plantar fasciitis and sore hamstrings

The most common treatments for plantar fasciitis focus on stretching the fascia and decreasing inflammation

Ironman training

I'm training for my first Ironman, which is three months away. But I was recently in an auto accident, and my injuries will delay my training for two weeks to a month. How much conditioning will I lose in that time? And are there guidelines for how I should increase my volume and intensity once I'm healthy enough to resume training?

Most studies have shown that fitness level decreases at about the same rate as it increases during training. Rest allows the body to recover and adapt to the high level of training required for an Ironman, and a few days of rest can increase endurance for dedicated athletes who are in a constant state of fatigue from consistent training. However, after about 10 days of complete rest, most athletes experience a decline in cardiovascular fitness.

The reason: Endurance training increases stroke volume (the amount of blood your heart pumps with each beat), and an extended period of rest quickly decreases it.

To perform at the same intensity (i.e., pump the same amount of blood per minute) it did before the period of rest, your heart has to pump at a higher rate. Take too many days off and your heart will have to work harder when you resume training.

On the other hand, if you simply reduce the frequency or duration of your training, but keep the same intensity level, you can maintain your aerobic conditioning for some time.

Let's say you usually run five to eight miles at 60 to 80 percent max heart rate five times per week. If you reduce that volume to four to six miles three to four times per week, but keep the same intensity (same heart rate), you'll maintain your aerobic conditioning for 15 weeks. You can decrease the number of miles and the times per week and not lose fitness, as long as you maintain intensity.

But don't rush it. Take however long you need to recover. And when you do get back to training, your fitness level will return at the same rate you lost it. That is, if you miss two to four weeks of training, it will take two to four weeks to get back to the same level you were prior to the accident. Start gradually, and increase your intensity, duration, and frequency of workouts over the two- to four-week period.

Keep in mind that any type of aerobic conditioning will help you maintain your fitness level. While you are recuperating, do other types of exercise (walking, elliptical trainer, stationary bike, etc.) for a stronger, faster comeback.

Plantar fasciitis

I've suffered from plantar fasciitis for six months and nothing I do (mostly stretching and strengthening exercises provided by a physical therapist) seems to help. Can you provide insight into what plantar fasciitis is, and what measures should be tried before surgery?

The plantar fascia is a thick band of tissue that begins at the base of your toes, runs along the bottom of your foot and attaches to the bottom of your heel bone. Stress to the plantar fascia may result in inflammation or tearing of the fascia, resulting in plantar fasciitis.

The most common symptoms are heel pain and tenderness. Pain is usually worse first thing in the morning when the fascia is tight and stiff. The pain is also generally worse at the beginning of a run and may gradually decrease as you warm up.

The most common forms of treatment include stretching the fascia, wearing soft heel cups, orthotics, night splints and medication (anti-inflammatories like Advil, Motrin, Aleve, etc). The goals of the treatment are to stretch the fascia and decrease the inflammation.

In persistent cases, treatment may include wrapping the foot and lower leg in a cast for about two weeks to stretch the calf muscles, Achilles tendon and plantar fascia. Also, a cortisone injection may help relieve the pain and decrease inflammation. However, multiple cortisone injections have been shown to increase the rate of plantar fascia rupture.

Another treatment, which has been supported in recent medical studies, is extracorporeal shockwave therapy. It's relatively painless and non-invasive but often requires multiple sessions. If you opt for this treatment, your doctor will ask you to stop taking anti-inflammatory medication about five days prior to the procedure.

The treatment takes about 30 minutes per foot and is performed under local anesthesia. Strong sound waves penetrate the heel area and stimulate a healing response by the body. Currently, many insurance companies do not cover the cost of this therapy, about $1,000 per treatment.

Surgery, which involves cutting the plantar fascia at the bottom of the heel bone to alleviate tension and inflammation, has a moderate rate of success, and should be used as a last resort.

Generally speaking, is there any rule for when to massage a sore muscle versus when to let it heal on its own? My hamstring feels tight and sore (more painful than general muscle soreness) after hard run workouts, and I'm wondering if massaging it will cause harm.

Massage can help relieve sore muscles by aiding in removing the lactic acid buildup in the muscle. Lactic acid can lead to inflammation, soreness, stiffness and fatigue. Therefore, massage can help reduce pain and swelling. It can also promote flexibility and faster muscle recovery.

However, you should avoid massage and seek medical advice if you develop a sudden sharp pain in your muscle or if you have persistent pain despite several days of rest. This pain may be a result of a partial or complete tear of the muscle or tendon. If this occurs, you may feel a defect in the muscle and develop bruising and weakness in the area.

Most hamstring tears are treated non-operatively unless they involve the area where the hamstring connects to the pelvis bone. These tears often cause pain deep in the gluteus muscles and usually result in a limp. They're often treated with surgery, which is done through a small incision and involves reattaching the tendon to the bone.


Robin V. West, M.D., is an orthopaedic surgeon and assistant professor in the department of sports medicine at the University of Pittsburgh. She is the head physician for the University of Pittsburgh men's basketball team, the department of athletics at Carnegie Mellon University, and an orthopaedic consultant for the Pittsburgh Steelers.

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