Doc’s Talk 06-10-2012

Dr. Scaff talked about shin splints and side stitches.

Shin splints and side stitches are both beginning training problems, and they usually disappear within a year of training; …if you continue to have them that is a real problem.

Shin Splints 
A shin splint is the beginning of a stress fracture on the front of the tibia.  As you run, it first appears as a soreness in the shin, later it becomes tender to touch, then swells, and then a stress fracture can occur.  

A stress fracture might not show up on an x-ray, but it would show up on an MRI or CAT scan; however, you don’t really need to get any of those diagnostics.  When you have a shin splint, it is just a little piece of bone attached to a muscle fiber that has pulled away from where it was attached to the tibia.  If you are curious what these bone-to-muscle attachments look like, the next time you are in the supermarket look at some ribs and you will notice that the meat attaches to the rib by many little fibers.

When you are training you are remodeling your body.  Your body was not used to running and the muscles are in the wrong place, so gradually some of the fibers pull off and then reattach further up or down the leg depending on what you need.  In other words, shin splints are a structural remodeling, but they hurt.  Shin splints usually occur when you are doing too much, too often, or too soon for your level of training.

Treatment of Shin Splints
The treatment for shin splints is rest, and laying off of running until you can walk without pain (see “Doc’s Talk 05-13-2012 The Beginner’s Guide to Injuries”), and then ice, then aspirin or ibuprofen – but never take the aspirin or ibuprofen before a run.  If you do that you hide the pain and can hurt yourself worse.  Take aspirin or ibuprofen only after a run.  Ice you can use whenever you want, it’s the most wonderful product there is.  If the shin splint pain persists after that, then you might have to see physician.  Just bear in mind that people go to physicians and get bone scans and spend money, …but a shin splint is going to primarily take care of itself.

The body is capable of “incapable” remodeling.  Dr. Scaff shared an example of this by referring back to a medical conference the Honolulu Marathon Clinic held in Hawaii with the Honolulu Marathon, where Ernst F. Jokl, M.D. from Germany showed photos of a man who was an Olympic weight lifter, all bulked up and muscular, who decided to become a marathon runner.  Four years later, he looked like one of the very skinny Kenyans.  He took his mesomorphic body, totally restructured it, and became a medalist in two different sports.

So the body is capable of doing a lot, but when you have shin splints it is telling you, “I’m trying to get better.”

Side Stitches
Side-stitches are pains, usually in the right upper-quadrant of the abdomenthat occur when you are running.  If the pain becomes serious it slows you down or you have to stop.  Side stitches are “geographic”, which is sort of interesting. For example, you may experience side stitches running up or down a specific hill.  “Here it is again!”  How did it know you were there?

Normally, when you take a deep breath at rest, your stomach extends out.  Your diaphragm, which separates the lungs from the abdomen, goes down.  The diaphragm is a thin but large muscle that covers an area from the front of the stomach to the back, but it is only about a quarter inch thick.  So when you take a deep breath the diaphragm pushes on the spleen, a small spongy organ in the upper left area of your abdomen, and on the liver, which is a big heavy solid mass in the upper right area of your abdomen.  The diaphragm pushes the liver down into the gut.  When you are running you have tightened your abdominal muscles, and so now you are taking a deep breath and the diaphragm is trying to push down against this intra-abdominal pressure, which it is not used to doing, and it develops a cramp.  Once it cramps up you are stuck for that day.

How to Prevent Side Stitches
If you get side stitches in the same geographic location along your run
anticipate it.  As you approach that specific part of the route, relax your abdomen.  The way you can tell you have relaxed your abdomen is that you have also relaxed your sphincter (like you were getting ready to go to the bathroom, but you don’t go all the way).  Also, bend over so you can let your belly relax, and then purse your lips as you exhale.  Pursed-mouth breathing increases the inter-thoracic pressure, helping to push the diaphragm down.  Then simply try and work your way through the side stitch.  If you know you are always going to get a side stitch at a particular location (e.g. the back side of a hill) before you get to that site start walking for a few minutes and then start running again before a side stitch forms.  Anticipate it.

Why do side stitches occur on the back side of a hill?  When we run we are generally perpendicular to the horizon, but the surface is not.  When running uphill we are leaning forward, when running downhill we are leaning backwards and stretching the abdominal muscles making the abdomen even tighter.  So if you just understand the physiology of this, 99% of the time you can take care of any side stitches without an expensive visit to the doctor’s office.  Besides doctors give the wrong advice because most of them have not had to work with side stitches.

For more information refer to Your First Marathon – The Last Word In Long Distance Running, by Jack H. Scaff Jr., M.D., F.A.C.S.M., available for purchase at the Honolulu Marathon Clinic on Sundays and online at:

Next Sunday Dr. Scaff will talk about why shoes cause knee pain, and about why shoes are bad in general.

Reminder:  Next Sunday is a bus run.  Everybody is afraid of the marathon, so the purpose of bus runs is to get you used to your fear of the unknown.  After all, when you are running back along the course 5 or 10 times you get used to it.  However, if you run from Kapiolani Park to the gas station and back, that is the same distance as running from Hawaii Kai, …but it SEEMS so far.  Bus runs are to help you get accustomed to this.  So that is the adventure of the bus run.  Make use of it!

For some good reading on nutrition, Dr. Scaff recommends everyone check out the daily postings on Dr. Alan Titchenal’s “Got Nutrients?” web site:

Here is a recent posting:

June 10, 2012
Adequate vitamin C intake helps to protect the body from oxidative stress. Despite not being clinically deficient in vitamin C, people with a low vitamin C diet showed much greater evidence of oxidative stress than people with a high vitamin C diet after they were each exposed to high oxygen concentrations in a hyperbaric chamber.

Consumer Link
Oh Limey, Where did my Spunk go?

Research Link
British Journal of Nutrition 14 June 2012 107 : pp 1645-1654