Friday, September 30, 2011

SwimSmooth: "Stroke Technique Is Even More Important In Open Water"

The wise, friendly and communicative folks at SwimSmooth have a recent blog post with the above title.  The main point they make is that bilateral breathing leads to a straighter open water stroke.  I'd say something more fundamental is also involved: Symmetric body rotation, independent of breathing, leads to a straighter stroke.

Though I'm a relative beginner myself, with just over 3 years in the open water and no freestyle swimming at all before that, I've spent the past two years helping beginners in the open water.  Basically, I started in, and never left, TCSD's (the Triathlon Club of San Diego's) beginner open-water swim clinic.  I first stayed around as a helper, and now (amazingly) as an assistant coach.

I work with a rotating group of 20-50 beginner swimmers every week.  Along with the leaders and senior coaches in our clinic, I suspect there aren't too many people around who regularly coach more true open-water beginners.

Our primary approach is to make open water swimming fun and enjoyable.  We've found that if a swimmer is comfortable in the water, then speed and distance will come simply because they will want to practice.  We don't get technical in our clinic, we don't focus at all on speed, and we focus on distance sufficient only to prepare them to survive and enjoy their first sprint triathlon.

"It is not possible to win a triathlon during the swim, but it is easy to lose one there."  - Common triathlon proverb

We focus primarily on 'functional form', and we teach a one-size-fits-all freestyle stroke that anyone can learn, a stroke that is optimized to get any beginner comfortably through the open water.  We don't explicitly target efficiency, and instead focus on teaching beginners to monitor themselves with every stroke and stay within their limits.

While I won't go into all the details of the stroke we teach, a primary component is to minimize all twisting of the neck.  We ask them to imagine trapping a small ball between the chin and upper chest.  That means in order to breathe, you must rotate your body!

Since we generally wear wetsuits in San Diego (the air is warm, but the ocean is cool), one of the greatest afflictions for new open water swimmers are neck rashes, more popularly known as 'wetsuit hickies'.  The cause isn't the fit or design of the wetsuit:  Eliminating neck rotation completely eliminates this problem at its source.

Surprisingly, we don't focus at all on bilateral breathing, other than to mention the reasons why it is a Good Thing.  What we do emphasize is having fully symmetric body rotation on every stroke, so that you always get one eye out of the water, even on the non-breathing side.  When a beginner later chooses to try bilateral breathing, their head will already be in the right position for it.

Yes, this may seem to be quite a lot of head and body rotation, and some folks do indeed experience dizziness or mild nausea while adjusting to it over the course of a few hours practice.  When this occurs, we suggest swimming with an extremely low stroke rate, about one arm per second.

We find that a low stroke rate not only makes the rotation more tolerable during the adaptation phase, but it also helps the swimmer focus on their whole body, especially the core, back and legs, instead of focusing only on using their arms to make progress through the water.  Many beginners twist and contort their bodies as they swim, and slowing things down helps them observe and correct this behavior on their own.

Many beginners lack upper body strength and endurance.  Here again, a very slow stroke rate has immense benefits, helping beginners avoid exhaustion and anxiety or panic (and the subsequent perception of wetsuit tightness we call 'neoprene smothering').  We focus on 'slow form' because, quite often, that's all the beginner swimmer can handle!

If you first find form and fun, fitness and fastness follow!

Another benefit of our 'no neck rotation' form element is that when the swimmer leaves sheltered water and encounters chop, surge and swells in the open ocean, they will then be able to easily add some neck rotation to get their mouth further away from the turbulent surface and thus make breathing more successful.

I've seen several fast open water swimmers with minimal shoulder rotation who experience nausea whenever they encounter even mildly unsettled conditions, claiming it was due to the 'rough water'.  I would tend to disagree: I believe it may have more to do with their having to add unaccustomed rotation to their stroke in order to breathe.  It seems best to address motion sensitivity while still a beginner.

Full, symmetric rotation not only supports a straight stroke, but also prepares the beginner for bilateral breathing and rougher conditions.

Another advantage of always getting an eye out of the water on the non-breathing side is that it vastly improves 'situational awareness' during a race.  We teach our beginners to draft to make the swim leg of a triathlon faster and easier.  When swimmers pass close by, it is tough to draft them if you never see them!

Proficient pool swimmers making the transition to open water often have the greatest difficulty learning 'full rotation'.  It seems they are so used to staring down at that black line that they often have great difficulty not only with rotation, but also with spotting/sighting in the open water.  They also tend to get the most wetsuit hickies.

Another complicating factor for pool swimmers is their insistence on kicking.  In a wetsuit, kicking provides little or no benefit, unless you have such a large motor that you have the energy to spare.  So another component of our beginner open-water stroke is minimizing kicking.  Most are able to eliminate it entirely, though a few folks need one kick per stroke to aid rotation.

The immediate benefit of eliminating kicking is that the body's energy stores are reserved for use by the arms.  For our beginners, it is important their energy lasts for the full session, and isn't exhausted too soon.

Since beginners tend to spend a long time in the water during their first few races, we do teach them to kick during the last 50 meters of the swim in order to get their legs warmed up and ready for exiting the water: This tends to eliminate the all too common "stand-up-then-face-plant" event at the end of the swim.  It is also useful for everyone at the end of an Ironman swim.

One more thing about pool swimmers transitioning to the open water: I've seen proficient pool swimmers be surprised and panicked after their first 100 meters in the open water due to unexpected exhaustion.  Removing the pool wall removes the flip-turn which in turn removes the long recovery glide their bodies are accustomed to having at the start of each length of the pool.  If they want to become good open water swimmers, I suggest they 1) don't let their feet touch the wall, 2) sight on the lane dividers instead of the black line, and 3) practice with a pull-buoy.

Back to the topic at hand: The stroke I've described is taught to beginners to help them become comfortable swimming in the open water and to ensure success in their first sprint triathlon.  After that, we encourage our 'graduates' to get lots of practice and to start attending the more advanced swim workouts and clinics our club offers several times each week.

I hope this hasn't sounded too heretical, but all I can say is that I've seen it consistently work well for many open water beginners.  We don't try to turn them into competitive swimmers, nor do we even try to help them find their personal, ideal stroke.  We try only to give them a basic foundation that works well, is easy to learn, and doesn't get in the way of having fun.

What may be a bit more heretical is that we also teach our beginners to glide.  We found that simply doing a slow-motion stroke is often not the best way to swim with a low stroke rate.  It is often better to combine a powerful stroke with a glide. This not only provides a brief recovery period during each stroke, but also builds strength and muscle memory while simultaneously helping the beginner become acutely aware of the overall shape and position of their body in the water.  If your body isn't straight, you will see yourself head off-course during the glide.  And, importantly, a short glide also momentarily halts rotation, further helping limit dizziness and nausea while learning 'full rotation'.

STROKE, glide, look-to-the-side, STROKE, glide, look-to-the-side.

The best thing about beginners learning with a glide in their stroke is that as fitness and conditioning improve, it is easy to reduce then eliminate the glide.  Conversely, if an intermediate swimmer becomes over-tired during a swim, briefly restoring a familiar glide can permit them to recover without stopping.  A glide is a Good Thing for an open water beginner to learn.

Though I've not discussed all aspects of the basic stroke we teach, some of the parts I have described may in some ways seem counter-intuitive or even wrong.  All I can say is that it absolutely helps beginners swim straight and far, then permits them to smoothly progress toward improved conditioning and higher speed.

Most importantly, it creates open water swimmers who have a blast in the water and race really well, staying on-course in the midst of a crowded field, even in unsheltered open water.

Tuesday, September 27, 2011

The Miserable Runners Group


I'm Bob, and I'm a Miserable Runner.

My goal is to use this Fall and Winter to become Less Miserable, and to run my first-ever half-marathon next Spring.

We all know the saying: "Misery Enjoys Company."  If that's not a great reason to start a running group, I don't know what is!

If you've been reading my blog you already know my story, but here's the short version:  For my entire adult life, running has never been easy for me, especially past the first mile.  I briefly ran 10Ks in my early 30's, but soon quit due to joint and foot pain that didn't go away for days.  Triathlon found me just over 3 years ago, just before I turned 52, and just as my body started falling apart.

My love of triathlon has not permitted me to quit running, and with each new (and old) running problem, I have kept studying the available resources, kept asking questions of doctors, physical therapists, coaches, academic researchers and fellow athletes, and kept learning and trying new techniques to improve my run despite my limitations.

I believe I finally have learned enough to pursue serious distance running with a greatly reduced risk of future injury.  However, I seem to lack some of the discipline needed to consistently apply what I've learned to myself.  I believe I will do much better as part of a group that meets 2-3 times per week.

I'd like this group to focus not on speed, but on comfort over distance.  To be able to eventually run long distances without stopping, and without injury.  Yes, we'll want to go as fast as possible, but speed will always be a minor concern, with comfort and safety always coming first.

I first want to focus on preparing our bodies for running, rather than simply strapping on our running shoes and making the same old mistakes over and over again.  This will involve basic muscle strengthening, improving balance and mobility, and (re)learning the motions and muscle use patterns needed to run comfortably.

In chats with other miserable runners, one common situation I've seen is that many people have no idea what a proper running shoe fit feels like!  While I can't fit a shoe to anyone's foot, I do believe I've learned quite a bit about how you can learn to go shoe shopping and find the best available shoe for your foot.  This is something that must be addressed before doing any serious mileage.

I want our group to be about running, not run-walk or jogging.  I'm talking about non-stop running, where we learn to manage our breath and energy so we don't have to stop due to overexertion.  Where we become able to continuously monitor our running form, and learn to stop running when our form starts to fall apart, long before we cause any injury or pain.  I want each of us to become able to do long distances at a 10 minute per mile pace, and shorter distances at a somewhat quicker pace.

Being allergic to pain (it makes me cry), I plan to do all the above without misery, but with lots of determination.  I think the phrase "No Pain, No Gain" does not and should not apply to age-group athletes.  Let the elites go down that path.  My goal is to find that place where "I Run Because It's Fun".

Also, I'm not a running coach.  I'm just a guy who has been frustrated by some major problems with his own running, and who has studied and tried lots of things to get past them. I still have questions, and I'm still learning, and I'd much rather do it as part of a group.

Most importantly, I'm done with injuries!  I want our group to be all about injury prevention and avoidance.  Safety and comfort must always come first.

So, would you like to join me? Please let me know!

Tuesday, September 6, 2011

Reading Your Own X-Rays

As triathletes, we often sustain injuries requiring some form of medical imaging to arrive at a diagnosis and a treatment plan.  The images will most often start with X-Rays, which if inconclusive may be followed by an MRI or CAT-scan, or on rare occasions a bone scan.  We then get a diagnostic pronouncement from our doctor, complete with hand-waving and finger-pointing in the general direction of the medical images.

The sad fact is, doctors are occasionally wrong, or at least not "completely correct".  I have personal experience with this.  Most often, they simply leap to a logical conclusion, a natural by-product of having only a 15 minute appointment to work with.  Other times they are "almost-right" or "right enough", and the prescribed care is adequate for the actual injury.  But sometimes "close" is not good enough, and much time can be lost pursuing ineffective treatments.

You should view your doctor as being an educated and dedicated professional, though one who is operating under lots of time pressure, who also is only human. The best way to improve your outcome is to be able to help your doctor as much as possible, to be able to help gather symptoms, to help analyze them, and to help find the best remedy.  A second way, of course, is to always get a second opinion before doing anything major like harsh drugs or surgery, or after an initial treatment fails.

If you had an extra 8-10 years, you could become a doctor yourself.  Well, for at least one specialty, if not for all the specialties involved with athletic injuries.  However, just because the knowledge mountain is truly huge, that does not mean there isn't lots of valuable and useful medical knowledge each of us can and should learn and learn to use.

The best place to start is with "A&P": Anatomy and Physiology.  Being able to name the parts of your body, know what they do, and know how they fit together.  While it may be interesting and fun to learn the whole body, the easiest and most useful way to start is with the specific areas of recent injuries.  And most of our pain and injuries tend to be in the legs and feet.

When studying a portion of the body, it is good to start from the inside and proceed outwards, starting with the bones and cartilage, then the ligaments, then the muscles and tendons, and finally the nerves.  But even that is a large amount of information.

So, rather than learn everything about even a single body region or subsystem, we can start by taking advantage of a fundamental property of our bodies: We have bilateral symmetry.  If we hurt on one side, the other side will likely be an excellent reference for comparison.  Instead of learning all about the injury area, we can start by looking for things that differ between the two sides.

When making comparisons, our eyes are our best sensors.  When looking inside our bodies, X-Rays give our eyes lots to work with.

A possible first step in this direction is to learn what your doctor is doing when ordering X-Rays.  A typical order includes the name of the body part and descriptions of the desired views.  But this is also quite a lot to learn: Most doctors don't remember the names of all the possible views, and tend to work from multiple choice lists.

What I do instead is simply request that the same exposures be taken on both sides of the body. This way, no matter what the exposures are, I will be able to compare the same views for two body parts: One injured, and one (presumably) healthy.
Many doctors will automatically order X-Rays for both sides, or will gladly do so if asked.  If the doctor won't order the duplicate exposures (citing issues of necessity, cost or radiation exposure), I've sometimes been able to convince the X-Ray tech to image both sides at once on a single plate (same number of shots).  The doctor may not need the additional images, but I sure do!

After the appointment, get a copy of the X-Ray images downloaded onto CD or DVD (a minor charge, if any, though there may be some paperwork).  I recommend waiting until after a radiologist reads the X-Rays, since his report will typically be included with the X-Ray data.

Next, you get to play Home Radiologist!  There are several free/open programs available to help you examine your X-Ray images (opening DICOM files, zooming, contrast stretching, pseudo-color enhancement, etc.).  You may need to try several programs before finding one that you are comfortable learning and using.

Before looking for any specific conditions, start with getting used to playing with X-Rays.  Most of the above programs include tutorials to help you learn your way around X-Ray images.  There are also several tutorials online that will teach you about what you can find by examining an X-Ray, though most of these tutorials are aimed at medical students, and are thus written in 'medglish' (Medical English: English with lots of Latin and Greek thrown in).

Next, learn the anatomy imaged by the X-Rays.  Much can be learned while viewing an X-Ray alongside a good anatomical reference (I use the images in Wikipedia and WebMD).  There are also many online sources for reference X-Ray images, such as MedPix.  Use these for practice until you get your own images.

Another great resource is your dentist.  Most of us get dental X-Rays taken twice each year, so there is lots of history, redundancy and variety to work with.  Most dentists are more than happy to share how they examine your images, and explain what they find.  My dentist and I have an ongoing contest to see if I can spot everything that's going on before she reads my images.

It can take many hours to 'train our eyes' (train our visual perception system) to 'see' (search for and find) subtle variations in X-Ray images.  Having lots of images to examine really helps, especially multiple views of the same part on both sides of the body.

I have well over a decade of my own X-Ray data for my back, knees, ankles and feet.  (Yeah, I'm getting older, and my X-Rays prove it.)  These images get more valuable not only with each passing year, but also with each new injury.

Three years ago I had knee pain that was diagnosed as being caused by ITB Syndrome, and a stretching regimen was prescribed.  My Sports MD also took X-Rays of my knees to ensure there was no other damage.  The nurse pulled the images up on a display, and while I waited for the doctor to return I correctly identified my own chondromalacia.

I didn't know that was what it was called at the time, nor what caused it, but I knew enough about X-Rays and basic knee anatomy to able to quickly spot the differences between the X-Ray images of my two knee caps, and to associate that with both my pain and the range of motion over which the pain occurred.

This skill really paid off for me very recently.  I had initially injured my foot last October, and everyone I talked to, including my MD, said it appeared to be a stress fracture of the second metatarsal.  X-Rays showed nothing, which is not unusual for first-time stress fractures.  And, sure enough, 6-8 weeks later I was able to gently return to running.

In a recent triathlon I again experienced sudden pain in the same place, but with less than half the intensity I had in October.  I decided to finish the race, with the commitment to immediately quit if the pain increased to its prior level.

Two days later I was back with my MD, who ordered more X-Rays.  To our mutual surprise, not only was no new break visible, but I immediately saw there was no hint of the bone thickening expected from the healing of the prior stress fracture.  We had a bona-fide mystery on our hands, and we decided to call in a specialist.

My MD gave me a referral to a podiatrist, who then diagnosed a problem with my transverse metatarsal ligaments (the ligaments that cross the foot connecting the heads of the metatarsals).  He confirmed that I had never had any significant stress fractures in either foot.  Fortunately, the treatment and recovery for both injuries is nearly identical (don't run, avoid causing pain, wait 6-8 weeks).  I'm in another recovery phase now.

The lesson here is that many physical ailments don't show up on X-Rays, so it is important to know not only how to look for damage, but also to know to look for expected characteristics that are missing.  Either way, learning your way around an X-Ray is valuable.

While few will likely want to get this involved in analyzing their own medical data (yes, I am an engineer), I do highly recommend everyone become comfortable viewing their own X-Rays, and not be afraid to say "Show me!" whenever a diagnosis is made from the X-Ray data, to typically be followed by asking "Where?", "Why?", "How?" and so on.

If you do get involved with reading your own X-Rays and decide to look at an MRI, you should know that MRI images are at least 10 times harder to analyze and interpret.  Even specialists have trouble with them, and recent studies have shown MRI to sometimes be a relatively poor primary diagnostic tool, and it has been shown to be almost useless for correctly diagnosing sources of back pain (leading to needless surgery that harms or fails to help the patient).  So be very wary when your orthopedist uses an MRI to justify a surgical remedy!  Ask if the same recommendation would be made without the MRI images, and insist that additional imaging be performed (X-Ray, CAT-scan, bone scan, ultrasound, etc.) before consenting to surgery or other risky or costly treatments.  And, of course, always get a second opinion.

You are the one who has to sign your treatment consent forms.  You have to go through the treatment.  You have to deal with the after-effects.  You are fully responsible for what is done to your body!  It is important that you learn as much as possible about the entire diagnosis and treatment process, and never blindly trust doctors (or anyone else).  The more serious the injury and/or the more drastic the treatment, the more vital detailed knowledge becomes.

X-Rays are a nearly universal diagnostic tool for finding and identifying structural damage.  Your doctor will order them either to confirm a specific diagnosis, and/or to exclude other possible problems.  Either way, the more you know, the sooner you will start the correct treatment.

I have not included any of my own X-Rays here, nor have I described the specific things I do to examine them.  This is intentional:  I want to avoid giving the false impression that I am any kind of an expert when it comes to interpreting medical X-Rays.

I am not a medical radiologist, though I do have extensive experience with industrial radiographic imaging.  I have developed several industrial imaging systems, and have trained operators in their use.

I am more than willing to list the tools I use and how I use them, but a blog post is not the best forum.  If you'd like a demo, please say so in the comments or contact me directly.  If you are local, I'll put together a small seminar.  If not, I'll try to learn how to make a YouTube video.