A Runner's Nightmare
by Jim Brown (3/31/98)

I'm going to describe a nightmare. You may not find it especially nightmarish -- many people, and even many runners, have faced much worse situations. But I think it's an especially instructive and thought-provoking nightmare -- with a moral that should give you pause. And for reasons that I hope will become apparent, it could be an increasingly common nightmare -- one that you as a runner may also face sooner or later.

Background

In order to get the right perspective on this nightmare, you need to have a bit of biographical information. I was born in 1950 - part of the so-called "baby boomer" generation that will swell the senior citizen ranks early the next century. In high school I ran track and cross-country. My high school running career could hardly be called "stellar", but in my senior year I did manage to run a 4:39 mile and a 10:20 2-mile -- still my PRs for those distances. After high school I didn't run for about 7 years. Then I took up casual LSD. (That's "Long Slow Distance", in case you had any concerns.) Two years later I started participating in road races, mostly 10K's. I didn't get to the marathon until 1982, but then managed about 10 marathons over the next 5 years. Between September of 1986 and June of 1987 I set all my long-distance PR's, including a 2:56 in the Toronto Marathon, a 1:18 in the Dexter-Ann Arbor half-marathon, and a 35:45 in the Dow 10K. During that same winter I also took up cross-country skiing.

Then the nightmare began.

The Nightmare

Later that June I developed severe pain in my right hip. The pain seemed to be deep in the joint, and it often felt as if a tendon or ligament were "catching" on something. At the time I thought the problem was related to some careless yardwork: trying to pull up a fence post with my bare hands while "sensibly" using my legs/hips for leverage instead of my back. I also thought I might have "set up" the injury during the previous winter by using improper skiing techniques that put too much strain on the hips.

I went to see my primary care physician, and he diagnosed the problem as sartorious tendonitis: inflammation of the sartorius tendon, which runs roughly from outside the hip to inside the knee. He admitted that the yardwork might have caused the problem, and even that skiing might have set it up, but his solution was predictable: stop running. Running would just aggravate the problem, he said, and I couldn't expect the problem to go away unless I stopped.

Reluctantly I took his advice for a while and switched to riding a bicycle. I dragged out my 20-year-old Raleigh 10-speed, added some equipment to make it more effective for aerobic workouts, then started biking religiously. By the end of the summer I was riding about 150 miles per week. Meanwhile, the hip pain got somewhat better, but only to a point. It never really went away.

I continued biking into the cooler weather, but that October my bike was stolen. (I'm still baffled why anyone would want to steal such a junky bike.) Rather than buy a new bike, I decided to switch back to running. The hip pain became variable: Some weeks I was virtually pain-free; others I limped. Eventually I asked my doctor to refer me to an orthopedic specialist, but the specialist had the same recommendation: Stop running.

I asked him what would happen if I continued to run. "You'll continue to have pain. As long as you run, you put stress on the tendon. Remove the stress, and the tendonitis will eventually go away."

I asked how long I'd have to stop running to get rid of the tendonitis. "At least 3-4 months, but maybe up to a year. Tendonitis can be very stubborn."

I asked why the problem hadn't gone away during the 3-4 months I was biking instead of running. "Biking affects many of the same muscles as running. You'll have to give up biking too -- at least the rigorous kind of biking you've been doing." Evidently casual biking would be OK. But then so would casual walking.

I asked whether there would be any long-term damage or degradation if I continued to run or bike. "Probably not. It's a matter of irritating the tendon. Generally, the more you do it, the more inflammation and pain; the less you do it, the less inflammation and pain. If you want to get rid of the pain, stop what you've been doing."

I didn't want to stop, especially if it was going to take up to a year to solve the problem. The pain wasn't all that bad. If the irritation wasn't going to cause any permanent damage, I'd just live with it and back off a bit whenever the pain got worse. That's been my strategy for the past 10 years.

Boiled Frog

Well, at some point during those 10 years the game changed, and my strategy became obsolete. Now I feel like the frog who ended up getting boiled alive because the temperature of the water was raised so gradually that he never realized he was in trouble!

This past November I ran the Parke-Davis 10K. Like most people who run that challenging race, I was disappointed in my time, but otherwise the race seemed to go well enough. The next morning my hip hurt, but that wasn't surprising. I had plans that morning to run the Beast, a 4.5 mile segment of the Waterloo Trail that is billed as the most arduous portion of the infamous Dances with Dirt 100K. I'd been looking forward to this run all week and was determined to go through with it. But this 9-mile out-and-back "fun run" turned out to be excruciatingly hard on my hips, even though I did it at a leisurely pace.

For the next week I hobbled around at work and had trouble sleeping at night because of pain that extended all the way from my hip down to my knee. I had been in similar pain for as much as a week before, but it had always gradually faded even as I continued running. This time the pain just wouldn't fade, and my right leg actually collapsed on me a couple of times during runs. Finally I went to see my doctor (a different one than 10 years ago). He ordered x-rays. The verdict: osteoarthritis.

Arthritis?! I was shocked and angry. Only old people get that! That's the disease you get when you're elderly, frail, feeble, sedentary, and helpless. Tendonitis I could live with; it was a mere annoyance. But arthritis struck me as a kind of death sentence for my active lifestyle. I had visions of the panic-stricken little old lady gasping into her monitor, "Help! I've fallen, and I can't get up." I almost felt betrayed. Running was supposed to keep me vigorous and healthy well into my retirement years. How could I have arthritis at my age? How could I have arthritis when I was otherwise in such good shape? I thought about all the couch potatoes who had warned me that I would "wear my body out with all that running", and it made me angry that they could now use me as an example to support their sedentary lifestyle.

Exploration

After the initial shock, anger, and frustration wore off, I decided to learn as much as I could about my newly discovered nemesis. In this endeavor I was aided enormously by the internet, including news groups like alt.support.arthritis and misc.health.arthritis. Here's a summary of what I've learned about this disease so far.

First of all, the term "arthritis" is used to cover a host of rheumatic diseases. For this reason it is often called "rheumatism". The common theme seems to be painful inflammation of the joints and/or connective tissues. Although there are over 100 different types of arthritis, the three major types are

In the United States, about 15% of the population is afflicted with arthritis, including about a quarter million children! Over 30% of the adult population shows x-ray evidence of osteoarthritis in the hand, foot, knee, or hip, and by the age of 65 it's up to 75%. I'm going to talk just about osteoarthritis of the hip because that's the problem I have. But much of what I have to say would apply to osteoarthritis of the knee, which is just as much a problem for runners and may actually be more common.

Osteoarthritis of the hip involves deterioration of the articular cartilage layer that covers the ball and lines the socket of the hip joint. The "ball" is the upper end of the femur, or thigh bone; the "socket" is part of the ilium, or hip bone. Initially (in youth) this cartilage is smooth, flexible, and slippery -- sort of like Teflon -- enabling the ball to move within the socket with minimal friction. It's also spongy, absorbing synovial fluid in between the impacts of running, then acting as a shock-absorber during each impact. With age this cartilage tends to dry out and become thinner and more brittle. It loses its shock-absorbing capabilities and also begins to crack and abrade, making it less slippery. Eventually, as the protection of the cartilage layer decreases, the femur may start to scrape against the ilium. The result is pain, swelling, and loss of mobility in the hip joint -- especially if accompanied by other age-related developments, like small bony growths, calcium spurs, or soft cysts in the area.

Arthritis experts generally agree that rigorous exercise, including running, does not cause osteoarthritis. According to the prevailing theory, the cause is genetics. If that theory is correct, a good analogy would be male pattern baldness. Whether, how, and when a man will lose his hair are largely determined by heredity. A number of other factors (diet, stress levels, environmental elements, etc.) may speed up or slow down his natural rate of hair loss, but the underlying rate is determined by his genetic inheritance. Similarly, whether someone will lose cartilage and which joints will be most affected are, according to this theory, largely determined by genetics. Running itself does not cause osteoarthritis, any more than frequent shampooing causes hair loss. But the rate of deterioration can be accelerated by injury, by skeletal defects, and by overuse/misuse of the joint.

In my case all these factors may have come into play to hasten the onset of arthritis symptoms:

On the other hand, the effects of the deterioration can be counteracted by exercise, which strengthens the surrounding muscles, enabling them to take much of the load off the joint, and also stimulates cell-replacement of tissues in the area, even to some extent the cartilage, which is nourished indirectly via the synovial fluid. Conversely, inactivity can magnify the negative effects by slowing tissue replacement and allowing the supporting muscles to atrophy. (Take that, all you couch potatoes!)

Treatment Strategies

Mainstream medical science and its spokesmen (including the Arthritis Foundation) consider osteoarthritis to be irreversible. But they allow that the deterioration can be slowed; the symptoms can be treated; and the condition can also be medically "corrected" on a temporary basis. Treatment strategies endorsed by mainstream medicine fall into five broad categories (in order of increasing cost and/or disruption to lifestyle):

  1. Dietary Modification
    • Improve Diet - Switch from fatty meats, eggs, margarine, shortening, dairy products, etc. to cold water fish, fresh vegetables, fruits, nuts, and whole grains.
    • Lose Weight (rarely applicable for runners): lower weight = less stress on the joints.

  2. Activity Modification - Switch from high-impact activities like tennis, racquetball, and running to lower impact activities. Here's a list of such activities, arranged roughly in descending order of benefit (strength, flexibility, cardiovascular conditioning) vs. cost ("wear and tear" on the hips):
    • water aerobics (including swimming, water-jogging, water polo)
    • indoor cycling machines ("exercise bikes")
    • stretching, yoga, non-weight-bearing calisthenics
    • bicycling on flat, paved terrain (recumbent bike is probably best)
    • rowing (including rowing machines) and crew
    • Nordic track and similar low-impact, weight-bearing apparatus
    • low-impact aerobics, Tai Chi
    • weight/resistance machines (e.g. Nautilus equipment)
    • power-walking on pavement or treadmill
    • in-line roller skating, ice skating, and roller skiing
    • kick-biking (with "scooter")
    • trail biking (with "mountain bike")
    • race walking
    • hiking on hilly terrain
    • stair-stepper and similar medium impact machines
    • traditional cross-country (Nordic) skiing (iffy on hilly trails)
    • skate-style cross-country skiing (probably best avoided)
    • backpacking and canoe-portaging (probably best avoided)

  3. Physical Therapy
    • Osteopathy
    • Physiatry and Occupational Therapy
    • Sports Medicine (e.g. orthotics)

  4. Pain Management
    • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): aspirin, ibuprofen, naproxen, piroxicam.
    • Steroids (e.g. cortisone shots)

  5. Surgery
    • Hip Arthroscopy
    • THR (Total Hip Replacement Surgery)

There are also "alternative" treatment strategies involving so-called "natural" remedies that are typically not endorsed by mainstream medical authorities:

Most of these alternative strategies are supported by anecdotal evidence rather than rigorous medical research, largely because of inadequate funding for any research. The reason is that most natural remedies can't be patented; so there's no "profit motive" to spur the research. However, the growing field of nutraceuticals has begun to spawn a fair amount of research into phytonutrients, essential carbohydrates, and various enzymes.

The best treatment strategies may be the first two: diet and activity. You have full control over them, and they're relatively cheap. Once you start taking drugs, you start to lose some control and can also expect to start shelling out some bucks. To some extent, the same can be said of alternative strategies. (For example, chiropractic can be expensive, and it's rarely covered by medical insurance.) In the case of drugs and supplements, you also have to worry about potential side-effects. (For example, there is evidence that prolonged large doses of certain NSAIDs can actually accelerate deterioration of the cartilage even while they temporarily relieve the pain. The result in the long run is a downward spiral of cartilage deterioration and increasingly self-defeating attempts to deal with the pain.)

THR should be the very last resort because, with current technology, an artificial hip never really works as well as the natural one and typically lasts only 10-15 years -- and that's with restricted use (i.e. no high-impact activities like running). Also, even though THR is considered a well-established and relatively safe procedure, any surgery carries risks. My grandmother went in for THR in her late 70's and developed an infection while in the hospital. Drugs used to treat the infection destroyed nerves in her inner ear and, therefore, her sense of balance. Ironically, she came out of the hospital with a functional hip, yet had to use a walker for the rest of her life because she was always dizzy.

My Strategies

In my own case, I initially focused on the first two strategies -- diet and activity -- but later began to supplement the dietary changes with nutraceuticals and the activity changes with physical therapy.

I have some reservations about the "lower impact activities" list: For my money, it's top-heavy with indoor activities and use of special equipment. I don't like working out indoors at all -- especially in a swimming pool, with its heavy chlorine odor, stale/humid air, hemmed-in atmosphere, competition for workout space, and inconvenient access times.

The nice thing about running is that it's so convenient and economical (both cost- and time-wise): You can do it just about anywhere at just about any time, and all you really need is a decent pair of shoes. Moreover, as far as I'm concerned, the best type of running is trail-running, which provides plenty of fresh air, interesting scenery, and challenging terrain -- although some would argue that it puts more strain on the hips than most road-running. (This is a matter for debate. The hilly, winding, uneven terrain of trail running puts more strain on the muscles surrounding the joints, but I think the unforgiving surface of city streets and sidewalks causes more shock to the skeletal system and therefore puts more stress on the joints themselves.)

Nevertheless, arthritis may force me to get used to some indoor workouts. During the warmer months I may be able to run, hike, or bike the trails near my home in Brighton, but in icy/snowy conditions those forms of exercise may become hazardous and could even aggravate the effects of arthritis. Skiing is a better alternative in such conditions, but the really fun kind of skiing (on winding, hilly trails through the woods) puts a lot of stress on the hips, while the "safer" skiing (on relatively flat open golf courses) is downright boring. Also, the ski conditions in the Detroit area are typically pretty miserable through most of the winter. Trying to ski in bad snow probably hurts the hips as much as running.

At any rate, arthritis experts insist that nothing else comes close to water aerobics for remaining active in the face of arthritis. Water's buoyancy protects the joints against impacts that cause further deterioration, and water's resistance maintains the strength and flexibility of the muscles that surround the joints. The only real drawback to water is that, by minimizing the effects of gravity, it removes the body's natural incentive to maintain bone density -- which can promote osteoporosis if not supplemented with at least some weight-bearing activity.

With these things in mind, I enrolled in a water aerobics class at the Howell Aquatics Center. This "Power Splash" class was about $45 and was offered only under rigid time restrictions, but it had the residual benefit of allowing my wife to work out with me for the first time. (She has never liked running, at least partly because she's never had the patience to get in good enough shape to keep up with me on my runs.) During the winter months I found this class to be somewhat helpful in keeping my hips limber, though not especially conducive to aerobic conditioning. (I suspect that swimming would be far more beneficial in that respect.) But as the outdoor weather became more congenial in spring, I found the water aerobics workouts increasingly boring and eventually dropped out of the class. If hip pain is still a major concern next winter, I may go back to the water aerobics class or take up swimming.

The indoor exercise that seems to have better staying power in my case is stationary bicycling. In fact, I've worked this exercise into a regular routine that seems to be paying off. Before each run, I work out on the stationary bike for about 10 minutes, then spend 10-15 minutes doing a series of stretching exercises recommended to me by a physical therapist. (The cycling warms the muscles, making them easier to stretch.) After the run, I do a similar stretching routine .

My overall strategy now is to use various low-impact activities, like bicycling and water aerobics, to supplement my running -- i.e. cross-training. I continue to run several times per week, but I've begun to treat my hips as a kind of limited resource, and I try to be selective about how/where I run. If running is going to put wear and tear on the hip joints, I don't want to waste my runs on relatively boring jogs down city streets and sidewalks. As much as possible, I try to channel my running into the trail running I enjoy so much. As long as I'm faced with the threat of pain, I figure I might as well get some compensating pleasure.

Nutrition

Meanwhile, as mentioned, I am also experimenting with diet and nutraceuticals. I've virtually eliminated meat, dairy products, and processed foods from my diet and now eat plenty of whole grains, nuts, fresh fruits and vegetables. I even joined a food coop in order to get these foods less expensively and in an organic form (i.e. produced without pesticides or chemical fertilizers).

My choice of nutraceuticals over other "alternative" remedies was based on a desire to attack the problem at its source rather than trying merely to relieve the symptoms. There are many so-called "natural" remedies that purport to reduce the pain and inflammation of arthritis without the side effects of NSAIDs, and some have plenty of anecdotal evidence to support them. But these remedies mostly deal with symptoms rather than causes. Nutraceuticals take a different approach.

Nutraceuticals contain concentrated nutrients that should occur naturally in our food supply, but don't because of modern food processing, transportation, and storage practices. Unlike most nutritional supplements, nutraceuticals are developed and tested in the same rigorous fashion as pharmaceuticals. Many are even patented. The theory behind the need for nutraceuticals is that a lack of certain key nutrients in the modern diet is largely responsible for the rampant increase in so-called degenerative and auto-immune diseases that are often attributed to genetics and/or environmental pollution. Certain people may indeed be genetically disposed to cancer, heart disease, adult onset diabetes, etc., and environmental pollution may indeed trigger those diseases in many people. But if their immune systems were healthy, they would be able to overcome the triggers and fight off the diseases. What causes their immune systems to fail is a gradual deterioration brought on by years of poor nutrition.

Key Nutrients

So what are the key nutrients missing from, or deficient in, the modern diet?

  1. Essential Carbohydrates: Recent biochemical research has determined that glycoproteins -- molecules found on the surface of all cells -- play a key role in all cellular communication. These complex molecules form the "language" of metabolic instruction, somewhat the way DNA forms the language of genetic instruction. Cells can synthesize glycoproteins, but only if they have sufficient quantities of 8 essential monosaccharides (carbohydrates) to use as "raw material" for the process. These monosaccharides include glucose, galactose, mannose, xylose, fucose, n-acetyl-glucosamine, n-acetyl-galactosamine, and n-acetyl-neuraminic acid. During the evolutionary development of the human species, all 8 monosaccharides were present in the human diet, which at that point was largely based on hunter-gatherer fare available in equatorial regions. Civilization and food-processing technology have gradually eliminated all but two of these essential carbohydrates (glucose and galactose). Ironically, while civilization and technology have produced advances in sanitation, medical science, and physical security that enable people to live longer, they have also produced the dietary and environmental conditions that contribute to the breakdown of cellular communication and the body's immune and repair systems. People live longer, yet they spend many of those extra years suffering the effects of various degenerative and auto-immune diseases!

  2. Food-Form Vitamins and Minerals: Many foods are processed in ways that inadvertantly remove key vitamins and minerals. Also, many people are just too busy to prepare and eat the variety of foods they need to get all the vitamins and minerals required for good health. Some food producers try to compensate for this shortfall by putting vitamin and mineral additives in the food, and some people try to compensate by taking vitamin and mineral supplements. But these additives and supplements are almost all produced by chemical synthesis (vitamins) or mined from the ground (minerals). There is some question whether chemically synthesized vitamins and mined-from-the-ground minerals are recognized as real food by the body, and the body may actually try to "filter" out some as if they were so many contaminants. Real food contains vitamins and minerals that are thoroughly bound up in complex molecular structures that the body recognizes as food and "knows" how to use based on thousands of years of evolutionary development.

  3. Phytonutrients: These elements support various defense mechanisms in the body and are now considered almost on a par with vitamins and minerals for good health. They are mostly found in naturally ripened fruits and vegetables but are largely missing from our modern food supply because our mass market techniques for transporting and storing food require that fruits and vegetables be harvested before they ripen so that they'll survive the trip to market without spoilage. Certain phytonutrients, called "plant sterols", are especially important because they support the endocrine system, which consists of glands, such as the pancreas and pituitary, that produce and balance hormones that regulate all metabolic processes, including those involved in the proper function of the immune system. The richest food source of plant sterols -- herbs from the dioscorea (wild yam) family -- are simply not present in most people's diets. When vitamins and minerals are missing from the diet, the result is diseases like scurvy and rickets. But when phytonutrients are missing from the diet, the result is degenerative diseases and cancers.

    The idea behind nutraceuticals is that restoring these three kinds of nutritional elements to the diet will improve cellular communication, which will in turn improve overall health. The underlying premise is that almost every disease can be traced to ineffective communication between cells -- either miscommunication (as in auto-immune diseases, like rheumatoid arthritis, where the immune system attacks healthy, normal cells) or lack of communication (which allows cancer cells, for instance, to grow unchecked).

    In my case, nutraceuticals seem to be getting rid of the arthritis symptoms. But I'm not ready yet to say they are entirely responsible for the improvement. Like pharmaceuticals, nutraceuticals are expensive, and I'd like to think that the various other measures I'm taking (water aerobics, warm-up cycling, stretching, and especially improved diet) are helping enough that I may not need the extra expense. In particular, I'm trying to find relatively inexpensive food sources of the essential carbohydrates and phytonutrients. In a way, I'm trying to achieve what amounts to a "paleolithic diet"! (For an interesting discussion of this concept, see Paleolithic Nutrition.)

    The Moral

    So what's the moral of this story? Well, there are actually three morals:

    1. Think about your eating habits. You may have the idea, as I did, that you can eat whatever you want because running burns off so many calories. But calories are only a small part of the story. Running puts considerable stress on the body. That stress certainly benefits the body given the right conditions. But poor nutrition provides exactly the wrong conditions, allowing stress to break the body down. Running provides many benefits, but it does not grant immunity from disease!

    2. Pay close attention to what your body tells you. If you have persistent pain in a joint -- whether it be hip, knee, ankle, or whatever -- back away from those gung-ho workouts and go get it checked out. Transitory pain in the muscles is OK; persistent pain in the joints is not. If the pains are in fact caused by arthritis, better to start dealing with the problem sooner rather than later. Trying to run through the pain will just accelerate the damage. Don't become a boiled frog! The longer you wait, the worse the nightmare!

    3. Even if you're convinced you're one of those lucky people not genetically disposed to arthritis, give serious consideration to cross-training. It's not likely to hurt your running, and it will give you room for error -- in case you turn out to be wrong about those genetics. If I had stuck with the bicycling 10 years ago, and perhaps added some other activities like water aerobics, I could probably have continued running at about the same level with little damage or discomfort, and I'd be far more confident now about reaching my ultimate running goal: To drop dead at age 100+ during a glorious trail run on a crisp colorful autumn day!

    Note: I regard this article as a "work in progress".
    • If you find anything in it that you believe to be incorrect or misleading, please let me know as soon as possible (josquin@tir.com or jbrown13@ford.com).
    • Likewise, if you have some information about arthritis that you think would enhance this article, please forward it to me or let me know how to obtain it.
    • Finally, if you disagree with any opinions stated in this article, please feel free to voice your dissenting opinion. I may very well change the article to reflect your opinion, provided you can back it up with solid supporting evidence!
    • For more information about arthritis, go to the Access Health Online Library. This library also has more specific information about Osteoarthritis.