Photo from Mount Royal, Frisco, Colorado.

"That is happiness; to be disolved into something complete and great. When it comes to one, it comes as naturally as sleep." - Willa Cather

Thursday 26 December 2013

Health Problems of the Endurance Athlete (Medicine in Running Part 2)

We are all familiar with the classic model of an injury: finger is bleeding. What happened? I cut it.

This model however very rarely works for endurance athletes. Instead health problems and sports-related injuries are almost always the result of many factors working together, often over a long period of time.

What athletes and recreational distance runners should be aware of is doctors are not trained in the health problems of endurance athletes. They see a young, "healthy" person with a disease or injury and assume the problem and solution are straight forward. For example: "you have anemia"  - "you must have heavy periods" (I will get back to the anemia example). Or your knee hurts - you must have IT band syndrome - but the why and the root of the problem eludes them.

When a runner writes to me via email or Facebook about a health problem they face that the problem is rarely, if ever, straight forward. Let's face it, I also know this from my own battles with health problems over the last many years.

In other words, when I see a runner, triathlete or someone who trains hard - a lot, say "I finally found out exactly what my problem is!" Before I know more details, I generally won't believe the solution to their problem is as simple as they think.

Take for example exhibit A: cytomegalovirus (CMV). This virus has come to the fore due to (Salomon) athlete Neal Gorman. He is an ultrarunner who was trying to figure our why he was feeling so tired and sluggish. He is NOT an athlete who contacted me for advice so I feel I can safely use him as an example without risking a breach of doctor-patient confidentiality. He was diagnosed with CMV. Normally this virus does not cause symptoms in healthy adults. He however had 1. elevated liver function tests and 2. the specific type of antibody which indicated active disease. He was given what appears to be the correct diagnosis by a very astute clinician who knew to look for this illness.

However, the underlying question is why. Why should a young, otherwise healthy adult get active disease (symptoms) from CMV when adults with normal immune systems who are exposed to the disease and don't react? He discusses openly his lack of sleep leading up to it. We can only speculate how much months of years of hard training led to a compromised immune system. (we already know the immune system of ultra runners is compromised following ultras - aka the "window" for infection of 3-72 hours, but what are the more long-term effects on the immune system?).

Read this article on Irunfar about the importance of sleep. Read these articles about overtraining: 1., 2, 3. I can not emphasize enough though that overtraining is far from simple itself. There are so many things that can predispose to it - or push a person over into having symptoms, but training is the one necessary component. (November 2012 when I went to the Urgent Care with lymph nodes and spit glands the size of fists, of course the doctor had no clue what he was dealing with - so we endurance athletes need to help care for each other and create awareness within our sport/s - and if it is our field of training and interest, contribute to high quality, non-biased research)

2. Take basically any viral or bacterial illness: pneumonia, mono (which, for some unexplained reason my 38 year old husband has - again, normally this is a disease of college students), sinusitis, any upper respiratory illness. The list goes on and on. Ultrarunners are NOT just exceedingly unlucky.

Let's face it: if we want to train to run ultramarathons, we have to get 1. adequate sleep (preferably 8 hours a night) 2. variation in our training and 3. avoid overtraining - ie, not just getting miles in for the sake of miles -or running too many ultras so we fail end the year with excess energy. (for once I AM ending this year with excess energy!) - that is the whole POINT of running: to get energy, to feel better!

3. Anemia (lack of red blood cells): I am including this because it seems almost every female runner I know suffers from it.

There are so many reasons for anemia in runners (and non-runners). Especially females. Sure, the ladies bleed regularly, but there is a small amount of bleeding from the GI tract every time you run and probably small amounts from muscle (that would escape through the urine). Then there is the increased need for iron, often not met with adequate dietary intake. Finally, there may be an element of gluten sensitivity (the amazingly complicated "story of wheat" and it's role in human disease remains to be fully elucidated, but I have a suspicion, though no proof it is contributing to anemia). I would be amiss if I did not also mention alcohol, which is toxic to the bone marrow. Finally if you add to this upper GI distress, ulcers, GERD, there is probably microscopic bleeding due to that as well.

I have previously been hospitalized with anemia (I was a 70 mile/week runner at the time). The thing that really confused the doctors was that I did not menstruate (how can a female who doesn't menstruate be anemic?). I learned a lot about anemia through this hospitalization. Normally they would have sent me home saying "sorry about your heavy periods", but a critical level of hemoglobin in a female who didn't menstruate was- well -freaky.

They sent me to get an upper endoscopy and colonoscopy and there was "nothing wrong". I almost got a bone marrow biopsy - and they might have muttered the word "cancer". At 23 years of age, it seemed wild.

I have now not been anemic for years. And what I have done is - improve my diet (increased protein & iron), given up gluten and take probiotics daily. (I am NOT saying this is your solution, but it was mine and it took years for me to find this solution.). And by the way, I DO menstruate now - barely, but it's there.

4. Depression. I am not sure if depression, fatigue or recurrent viral illnesses is the most frequent problem among endurance athletes, but the big D is certainly the most important one to discuss.

Depression also scares doctors (like it scares everyone). I am going to go out on a limb and say that ultra runners in particular may have depression tendencies (or mood disorders) to begin with. One of the most amazing things about running is it is a mood stabilizer/improver. And by the way, I just read that "dirt" - just breathing it in - can be like a dose of prozac. Nice.

I have on multiple occasions been forthright about why I started running - and that was because I could not sleep. And no sleep = depression no matter what kind of genes you have.

There are so many reasons a person can become depressed. There is no doubt that there are genetic tendencies towards depression. But there are also clear triggers and aggravators.

Again, I know this first hand. It probably would be a really difficult subject to write about depression if I didn't.

Two years ago at Christmas, I had lost a lot of weight. I had also run a lot of long races post-partum. I am well aware that setting a marathon PR 2½ months post-partum is not "normal", but it was so dang gratifying to me. I had no clue the cycles of mania and depression it would send me on (I had experienced them before, but never so rapidly or to that extreme). I don't even know if it was the post-pregnancy training alone - probably that in combination with hormonal swings, weight loss, lack of sleep and the stress of constantly moving between countries and doing a PhD. But it is clear that 1. overtraining and 2. rapid weight loss/low BMI are triggers for my "bipolar". I do not even know if it can be called "bipolar" with these as triggers, but I do not doubt that everyone has triggers for their depression (or mania) and that mood and other psychiatric disorders can be to a certain extent managed by identifying triggers.

I also noticed that depression tends to be worse around Christmas. Two Christmases ago I was in a hopeless state. Last Christmas I felt I was getting better, but could not stop crying at two Christmas parties in Denmark--- I had to go hide in bedrooms. I was even diagnosed with major depression but then went back to the doctor a few weeks later and it was - gone. (I have to mention my sister in law, Beverley, a psychologist, who helped me enormously at this time last year).

There are a lot of things around Christmas that lead us to depression (the expectation of being happy, low Vit D, fatigue, loss of control) which is why I chose to write this post today.

And that brings me to the last health problem of this post: injury. In ultra running or long-distance triathlon, injury is so rarely  "if only I hadn't stepped in that pothole". Injury is repeated misuse of the body without adequate rest, cross training, healthy diet and sleep.

I can not encourage you all enough to get into a good pattern that you can stick to the rest of your life.

The last two weeks I have been on constant cross training (I have only run twice). I absolutely love cross-country skiing, snow shoeing - and you throw swimming and yoga in there and I am as happy as a clam. I thought today - if there were beautiful powder snow all year long, I might never run again. (of course I would)

Over the last year, I have been the healthiest I have been since I can remember. As far back in my memory as I can go as a child, I suffered from stomach problems. I have been injured every year  -except this one - since I was 22. This year, no injury has lasted longer than a week. I have the old hip problem, but it is improving. Folks, this is not just luck. I even stopped at Desert Solstice 24 hour in time (after 50k) before doing any permanent damage. I know that it was not my achilles per se that was acting up, but a long season of hard ultras (and improvement I never dreamed of) and a body that needed a break.

Here is a brief list of a combination of things that led to a healthier, happier (and faster) year:

1. Giving up wheat and taking probiotics and well as generally cleaning up my diet (no artificial sugars, no high fructose corn syrup) has apparently helped.
But it is not just this.

2. I have changed my running style to pose - so the stress is more on the muscles than the joints. I may land on my heal some (most) of the time, but at least my knee is bent so my hips and back aren't taking the brunt of the stress. And it is a more efficient style with more rapid cadence.

3. And it's not JUST running style, it is respect of the body and knowing when it is time to rest.

4. It is also prophylactic rest. Don't run every day. Take at least a day off a week. Some people say do nothing, but I say cross train. Nothing super hard, but just get out there are use your muscles differently. And I am really feeling great with this couple weeks of cross training. I know Chrissie Wellington, Kilian Jornet, etc. recommend an "off-season"

5. Sleep. (and sleep well- no caffeine in the afternoon or night. And NO BABIES ;-)) There is a Flaming Lips Song that says - "you have to sleep late when you can and all your bad days will end". I love this song, but the real truth is, you have to sleep early when you can. If we had not gotten an au pair, I never would have started achieving this!! (hard to underestimate the importance of this on my health these past 6 months!)

On that note, my family and I should probably sleep. But I have to say how thrilled I am to for the first time in 3 years to NOT be depressed on Christmas.
SLG, Mattias, Meow, Christian. Christmas Eve.

Grandma Joyce, Mom, Christian, Emily, SLG, Mattias &; Meow

Nashota Park today. 15k skate ski. The thing I didn't know about skate skiing was how awesome it is as a workout of core stabilizing muscles. I actually didn't know what it felt like to have sore core stabilizers before beginning skate skiing. Will I be ready for the 50k Birkie on Feb 22nd? (I doubt it!)

Snowshoe running + sled surfing with Christian on North Lake.
Out skate skiing with SR before he knew he had mono! We miss you SR and wish you weren't working seven 12 hour shifts in a row!

Final note: if you are interested in learning about advancements in health-related research in ultra running, you may consider attending the Medicine & Science in Ultra Endurance Sports conference in Squaw Valley June 24th-25th. I will be there and this is one of the few (if not only) venues for discussing heath as exclusively related to endurance exercise.  I only hope that I can run Western States the weekend after (that will require placing in the top 3 females at the Ice Age Trail  50 miler).

Running/Skiing Song of the Day: so happy to run across an old fave "Stutter" by Elastica.


Robyn said...

Thanks for this thoughtful post.

On your last point (depression and other mental health issues), my suspicion has long been that endurance sports have a particular appeal to some people with a history of depression, addiction, maybe other things too. Look at the number of recovering alcoholics and other addicts in the ultrarunning community (and how some have substituted ultrarunning for their previous drug of choice). It's certainly a healthier "addiction" to have, but I think for some it's just as necessary. I suspect that ultrarunning attracts people with this inclination, rather than being a /cause/ of depression, etc.

The iron deficiency anemia thing is of course personally interesting to me. Did you figure out the cause of yours, when you were young? I had a similar extensive (outpatient) workup for mine recently (maybe now that it's finally done I'll do a follow-up blog entry) and all we found was inactive H. pylori gastritis. Which I'm not convinced wasn't a red herring. Treated it anyway, and a few gallons of Floradix iron supplement later, I'm running better than ever. I'll keep on supplementing my iron, even though my diet doesn't look very iron deficient, because it's working for me.

The conference in Mammoth sounds fascinating. I wonder if I can pass it off as CME? Will there be much pathology covered? :-)

Have a happy and peaceful Christmas holiday with your family. And good luck with the residency match!

Coach Jen said...

Great post and things that those outside endurance sports often forget! I recently (and a few times in the past) had a work up for anemia and no one ever seems to care that I run, ugh!

That conference sounds great, wonder if I could pull it off for CME, any trauma covered? ;)

Fast Bastard - World's Fastest Hematologist said...

I have to weigh in on the CMV and on the anemia.

1. CMV. We have to keep in mind that CMV infection comes in two flavors: primary infection and reactivation. It would be interesting to learn what form your Salomon teammate had. For primary infection, it probably does not matter much whether you are an endurance athlete or not. One could argue that athletes are whinier about, I mean more in tune with, their bodies. Don't forget that people have CMV infections all the time. 90% of adults have had it, and most probably thought of it as the cold or the flu or something similar.

If he had CMV reactivation, that's another matter. I suppose it could be possible after extreme endurance events like Ironmans etc. But it is usually seen in HIV or leukemia/transplant patients.

2. Anemia. I don't think you get anemia from muscle break down. You get myoglobin release, which may show up as blood in the urine on testing (but is not). What you may get is a low-grade stress hemolysis (in addition to the blood loss from the gut).

But. The main reason for anemia in endurance athletes is increased plasma volume. So for many, it's a relative anemia, akin to what is seen in pregnancy.

3. Adult mononucleosis (from EBV or CMV) sucks.

Robyn said...

I agree that endurance athletes frequently develop a relative (dilutional/"pseudo") anemia. However, let me risk an argument with a hematologist. (It's okay, I'm a pathologist, I argue with everyone.) Iron deficiency anemia (i.e. microcytic, hypochromic anemia with low iron indices) and subclinical iron deficiency (normal Hb with low ferritin or elevated transferrin receptor level) is also very common, especially among women endurance athletes. There are several small studies estimating the frequency at 25-50% (for example, see and Anecdotally, there are certainly a lot of women ultrarunners who, when tested, find their ferritin level very low. This is a different animal from dilutional anemia.

Sources of loss are debated, but insensible losses due to hemolysis, urinary tract losses, and GI trace losses have been suggested. Some women athletes probably have deficient iron intake due to dietary habits -- but not all of us. (I eat paleo, so it's all meat and veggies, all the time). I have wondered whether there could be something about endurance training that negatively impacts dietary iron absorption.

As for CMV: CMV rates vary considerably by geography. In Seattle, the seroprevalence of CMV in the blood supply (which might not be perfectly representative of the adult population) was 80%. I think it's similar in the Twin Cities. In other places, it's higher. Probably lower in some populations. I agree that athletes are more likely to notice a primary CMV infection than nonathletes, since we demand more of our bodies all the time. I hope you recover from your infection soon, and are back to enjoying the beautiful snowy winter!

Danni said...

Skate skiing is really hard.

I am impressed by your increased balance and introspection.

sea legs girl said...

Ok- first of all sorry about all the typos in the first iteration. My goodness that was painful to reread!

sea legs girl said...

Robyn, regarding the anemia- at the time the cause of mine was not discovered. I was found to have clostridium difficile (how I got THAT is a mystery in itself) but that is not supposed to cause bleeding. And my anemia was normocytic. The thing that got my blood count up was a transfusion and then a week of no running + eating liver for dinner. That way I got out of the bone marrow biopsy.

sea legs girl said...

Oops. There will be CME at Squaw Valley, Robyn. I hope you can come!

sea legs girl said...

Jen- awesome. Yes, I thought this conference might interest you! No specific trauma on the list. You can see a preview of the talks here:

sea legs girl said...

Fast Bastard, I believe mono is caused by only Epstein-Barr virus (EBV) and not CMV. See here:

Robyn said...

Primary CMV infection can cause a syndrome clinically identical to EBV mononucleosis. It's sometimes called CMV mono.

sea legs girl said...

Robyn, would that cause a positive mono spot test? SR's was positive so I thought that meant it had to be EBV??

Btw- another contributor to my anemia back in the day was probably my daily proton pump inhibitor.

Robyn said...

Yes, CMV can cause a positive Monospot (heterophile) test. You would distinguish CMV from EBV by measuring either CMV and EBV antibody titers, or viral DNA levels.

sea legs girl said...

Robyn, hmmm, okay, but in all fairness the monospot is nearly 100% specific so false positives from CMV should only be considered exceedingly rare and CMV should not NORMALLY cause a positive mono spot. Here is a recommendation from the AAFP:
"The possibility of acute CMV infection should be explored if a negative heterophil antibody test rules out EBV mononucleosis."

See more here:

Fast Bastard - World's Fastest Hematologist said...

I had to look it up, but I agree with SLG. The heterophile antibody test is specific for EBV infection. I even found some older sources referring to CMV mononucleosis as "heterophile negative mono".

Being the mononucleosis index patient, I can report that I am getting better by the day. But I can honestly say that adult mono is the most miserable thing I have ever experienced.

Hopeful said...

Love this post. Happy New Year to you and your family!!!!
Jennifer - Lincoln NE
Thank you!

Anonymous said...

I love this post. There is so much great information here for all athletes to consider - thank you for taking the time to share your experiences, including the more sensitive details. I would be curious to learn more about any associations between mental health issues and running - I'm not sure how much research is out there now, but it would be a really interesting topic to explore in depth. I'd also love to learn more about the effect of high-level exercise (like ultrarunning) in TREATING mental health issues. Thanks again for a great post and happy new year!


sea legs girl said...

Thank you Jennifer. And great questions, Kate. I would love to know more, too. Starvation is certainly linked with mental illnesses, but exercise in itself....? I think it would really depend on what kind and how much. I would love to know more. I know that Bikram Yoga has been associated with decreased depression and improved sleep. Certainly 'exercise" (loosly and variously definted) has been many times linked with improved mental health and decreased depression, but when it is too much and causes the reverse, well, I think the way overtraining affects the mind and body is only beginning to be explored. And what exactly constitutes overtraining for one person might not for another. And how much intensity in training matters is also not known. LOTS of opportunities for research!

Health And Safety Consultant Norfolk said...

I want to know what if the athlete don't want to retire from the profession but because of his age he needs to get retire. I have a friend who is an athlete, he is fit but now the problem is, some people are discussing about his retirement, so he is a bit afraid.

Arnold Brame

Rachel Kelley said...

Tracy, I have been following your blog for years...before you had two cute little boys :) This is my first time commenting on your blog, even though I ready it weekly(or as often as you post) I have to say I love your writing voice, its a terrific mix of personal, musical, and quantitative/research material.
I have to agree with your point about anemia and gluten/wheat intolerance...for years i couldn't figure out what was causing my anemia and my lack of nutrient absorption (I grew up with a hippy mom who never allowed sugar, food additives-it was all whole organic foods) but it was heavy on wheat...once I stopped eating wheat I gained weight and actually started having normal blood lab results. That is until i ran my first 100 this fall (pinhoti 100) This is my first time anemic again, but as you state, it makes sense that probably small tears in muscle and possibly in my digestive tract could cause my anemia again. This of course puzzled and alarmed my GP.
Anyway...that was a bit of a tangent. Just wanted to say thanks for writing such interesting and informational posts. Good luck with your residency interviews!

ps, enjoyed your interview with ElevationTrail too!

sea legs girl said...

Arnold, please send me an email with more info if you get a moment. I would need to know more about this athlete, what his sport is and goals. Thanks!

Rachel, I have absolutely cherished your comment the last couple weeks and I regret I haven't responded to it until now. THANK YOU! I also want to recommend the book Wheat Belly to you which does a great job describing through research why wheat alone causes many health problems even for people who don't technically have celiac disease. It is written by a physician from Wiscsonin and hs shed a lot of light onto the topic for me.

kathleen said...

ha. i just read about the whole dirt helping your mood thing too. it's funny because i haven't been able to run due to the cold/snow and not having anyone to watch my kids. i would love a treadmill, one day. but i have gotten really addicted to gardening. i have put aside my fears of getting legionnaires disease from bags of soil and started growing peppers and tomatoes in my basement under grow lights. it's been helping the winter go by. when i read the dirt/prozac i thought maybe that's why i am obsessed with planning my garden. as an aside, i better have darn good home grown food come spring. anyway, i too was depressed over christmas and i really thought i needed to be medicated. i even went so far as to write my psychiatric resident friend but it went away. no idea what that was about.

Anonymous said...

I've been scouring the internet for weeks now looking for a runner that has been hospitalized with Anemia. You are the FIRST I've found.

About two months ago, our 14 year old daughter started to feel "fatigued" when going about her normal schedule. She is a cross-country runner and soccer player. We felt it was normal for her to feel fatigued with all of that activity. It was also very hot - so, we thought she was dehydrated. We gave her more food to take to school and more water and felt that it would make her feel better. She then had a cold and sinus infection - so, we thought that was why she was feeling tired. However, after completing her course of antibiotics - she still felt very fatigued.

At the urging of her cross country coaches we made an appointment with the first available doctor to see if she was iron deficient. We didn't see her primary care physician - just another doctor within the same group. He said her hemoglobin count was at 8.2 and that she was iron deficient anemic. So, he prescribed iron supplements three times a day and said to come back in three weeks and she could go about her normal schedule with NO DECREASE in activity – just “don’t push yourself” he said. By the way, she doesn't menstruate, which should have been a HUGE RED FLAG for him.
After one week of iron supplements, we continued to see a decline in our daughter's demeanor and color. The cross country coaches spoke to me and my husband again and said we should take her in earlier than three weeks for a follow-up. They suggested to go by the next day. So, on Friday, October 3 we took our daughter to her primary care physician and sure enough her hemoglobin was lower than one week prior. She was at a 7. The doctor told us to take her to the ER immediately and she ordered STAT tests. They found blood in her stool - which indicated that she was bleeding internally in her GI tract. They admitted her on Friday night and gave her a blood transfusion on Saturday morning when even with IV fluid - her hemoglobin continued to drop.

After the transfusion and in four days, she was tested via endoscopy, colonoscopy, CT and Nuclear scan. All of which turned up negative. However, after the transfusion and medication for ulcers - her blood count was going up!! This was fantastic news as it shows that bleeding has subsided. When we left the hospital, her hemoglobin was at 10.6!! Doctors were happy and amazed as normally with transfusions, patients only go up one point. A camera pill test and all biopsies performed turned up negative as well for anything abnormal.

Now, three weeks post hospitalization and transfusion - she is thankfully up to 11.8 hemoglobin - still just under normal (HCT, RBC, WBC all normal again). Her serum iron is high due to transfusion. But, her ferritin took a dive to 7. We were told this is due to her making a ton of new blood. She cannot take a heavy amount of iron supplements due to transfusion - it would be overload. However, we've upped the iron in her diet and will have a cbc every two week and she takes a multi-vitamin with iron in it with orange juice.

She is now clear to do one physical activity per day. Whether that is PE or running or soccer until her next CBC result.

My question to you is how low was your hemoglobin and ferritin when you were hospitalized? How long until you were able to perform back to normal?