Defining Winning in Endurance Sports


About 10 years ago, I participated in a local half-marathon.  My father came out to watch the race.  After the race was over he commented to me, “Brian, a lot of people sped up and sprinted across the finish line.  But they were well behind the winner of the race.  Why did they bother, since their finish times were irrelevant?”

In perhaps 2008 or 2009, Torbjørn Sindballe, a phenomenal professional triathlete, published an article in, I think, Triathlete Magazine.  In this article, he described his perennial struggles with heat in competitions, especially the Ironman World Championship in Kona, Hawaii.  With the help of a creative sponsor, Sindballe developed a number of improvements to his race strategy, including wearing white and using gloves filled with ice.  What I remember most about this article is that, after having used his innovative approach, he came in 3rd place and stated, in the article, that he “won.”

“What?” I thought.  He finished 3rd, right?  That means two people, Chris McCormack and Craig Alexander, finished before him.  How could anyone who can count call this a “win?” I was relatively new to triathlon at that time.

Many non-endurance athletes and even many endurance athletes, themselves, have narrow definitions of success.  First place or bust.  Podium or bust.  Qualify for Kona, Nationals, Worlds, etcetera or bust.

Attached to this idea is the concept that not achieving such narrowly-defined success reflects a lack of commitment to becoming better.  “That middle-of-the pack guy must have been watching television and munching on chips when he should have been on the bike.”

I wrote an article a few months ago about how it is becoming more difficult to qualify for Kona. This was not meant as a complaint, but instead as a source of information upon which to reflect.  A well-meaning, and highly-motivated, reader looked up my (humble) results from past competitions on Athlinks and wrote me a detailed analysis of how I could qualify for Kona.  I just need to bike a little faster and take, oh, about an hour and a half off my marathon.  But, if I just train really, really hard, I’ll be right there in Kona.

I have had occasional highly-placed finishes and have qualified for Nationals several times. But I have also had surprisingly poor finishes in which I worked just as hard, or harder, as I had for podium finishes.  These experiences, and paying a lot of attention to the athletes around me, have taught me a lot of lessons about winning.

Now, please understand, I do not think that everybody should get a medal just for showing up. I think that graduation certificates for preschool and kindergarten, for instance, are absurd. Winning, however, for some people, can be just showing up (e.g. overweight couch to running a 5K is a wonderful win), but I am trying to make a different point.

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Here is my definition of winning in endurance sports:

Winning, in endurance sports, is doing everything you can with what you have been given, without quitting and without feeling self-pity.  

To make an extreme example, recall the story of Jon “Blazeman” Blais.  He had ALS and participated in the Kona race.  His finish, in almost 16 and a half hours, was magical. I will never forget watching footage of him rolling across the finish line. In simply finishing, he won. I have been in a lot of painful places in a lot of long races, but I cannot imagine how much agony he went through to win, on his terms.

This is just the point. Blazeman, and any other endurance athlete who pushes his or her limits, is a winner.  Some of us are born with magnificent athletic gifts, but most of us are not.  But this does not mean that a 50th place finish has any less value to that finisher than the winner of the race if that middle-of-the-pack finisher gave his or her all.

I also hold that the opposite is true.  Losing is not appreciating or using the gifts you possess. For example, I have a friend who is a really strong multi-sport athlete.  In a race a couple years ago, volunteers did not point him the right direction on the bike, and he ended up going some distance off course.  This made it pretty unlikely he was going to podium.  What did he do?  He turned around and biked back to transition, collected his gear and went home.  This behavior may be understandable for a professional who is having a bad day and decides to save his or her energy for the next race.  But this friend is an amateur and this was a short race which would not affect future training or performances.  Essentially, things weren’t going his way and he just quit.

Like everybody else at the start of races I am nervous.  Sometimes I ask myself, “what am I nervous about? Nobody but me really cares about my finishing time and I know I can finish.”  I think sometimes what really scares me is the thought that I may, in the course of a race, lose my commitment to being my best and just become the guy who packs up early and goes home. May this never happen to me or to any of us.

Here is to the winners in all of us.

Photo Credit: christopherbalz via Compfight cc

Exercise-Associated Hyponatremia: Endurance Athletes Beware


Exercise-associated hyponatremia (EAH) is an important, amazingly common, and potentially life-threatening condition that affects athletes who participate in sustained activity.  It is also preventable.  The following is a true vignette.

An experienced, very fit, non-anorexic, middle-aged female, accompanied by family members, hiked up to a 14,000+ foot summit on a mountain in the United States. She had spent three days acclimatizing before this hike. Her nutrition on the morning she began the hike may have been an energy bar (at around 6 AM).  During the hike, she had an apple and a handful of nuts, but not much else. She was mainly thirsty, not hungry.  To sate her thirst she drank water that had been collected and filtered from streams along the way.  She did not carry much hydration from the start to minimize weight and she did not add electrolytes to her filtered water.  

She summited the mountain and began to descend back down the trail.  At around 1 PM, at about 10,000 feet of elevation, she began to complain that she felt “weird” and had a headache. She developed increasing disorientation and fatigue and then began to develop very unusual behaviors, which she does not remember.  Her confusion continued to progress to the point at which she was unable to speak.  She then began to stumble and could not stand.  She was carried, using a makeshift litter, by Good Samaritan hikers to a location further down the mountain.  While being carried, the woman experienced a “full body seizure.”  A rescue team had been contacted.  When they arrived on the scene, according to their report, the woman was responsive to painful stimuli only.  She was unable to speak or to follow commands.  She then vomited.  The rescue team, which, along the way, grew in size to 13 individuals, carried the patient down the mountain to a waiting ambulance.

She arrived at the hospital at approximately 3:45 AM and had a very low sodium of 118 and a reportedly normal head CT.  The woman was intubated (a breathing tube was put into her throat so that her airway could be protected and physicians could control her breathing) and she was airlifted to another medical center.  She received IV fluids and a repeat head CT reportedly showed brain swelling.  By noon on that same day, her sodium was normal and she was extubated.  However, her creatinine kinase (which is released when muscle is damaged) was very high at 27,000 and she was kept in the hospital for 3 more days until this level dropped to 3,000.  

This very fortunate woman is alive, well, and, apparently, has no lasting damage from this event. This is fantastic news.  Unfortunately, other people have not done as well with exercise-associated hyponatremia.  There have been a number of known fatalities from this condition (at least 14 in athletes since 1981).  As recently as the summer of 2014, two otherwise healthy 17-year-old high-school football players died from hyponatremic encephalopathy, which is the usual cause of death from EAH. Deaths from EAH have occured during participation in the following activities/sports: marathon, canoe race, hiking, military exercises, police training, American football, and fraternity hazing.

Definition of exercise-associated hyponatremia

The lower limit of normal for sodium is 135 mmol/L. EAH is defined as a sodium value below 135 occurring up to 24 hours after exercise.  This condition is often asymptomatic.  But a much lower level of sodium (below 125) and a more rapid, but smaller fall to higher levels of sodium (as high as 130) can be associated with symptoms.  The individual described, above, with a sodium level of 118 had a critically low level.   

Epidemiology and Presentation of EAH

Prior to 1981, athletes were advised to avoid drinking during exercise (doesn’t this sound nuts today?).  This led to a number of cases of hypernatremia (high blood sodium).  Therefore, authorities, around 1981, began to suggest drinking as much water as possible during exercise. This led to a number of cases of EAH and ongoing misunderstanding about the dangers of overhydration.

EAH can be asymptomatic or symptomatic.  Symptomatic individuals can have mild symptoms such as lightheadedness and nausea or more severe symptoms such as headache, vomiting, confusion, seizures, and respiratory distress.  The confusion and seizures arise from swelling of the brain (exercise-associated hyponatremic encephalopathy) and the respiratory distress arises from non-cardiogenic pulmonary edema.   

Asymptomatic EAH has most prominently been noted in 161-km ultramarathons, in which the incidence has ranged from 5% to 51%.  In Ironman triathlons, the range of incidence has been negligible to 25%.  For cyclists participating in a 109-km race, the rate was reported as 12%.  In a 26.4-km swim, the incidence was 17%.  For marathoners, the incidence has ranged from 0% to 13% of finishers. After an 80-minute rugby competition, premier league UK players had a rate of 33%.  Finally during a 28-day training camp, 70% of elite rowers had asymptomatic EAH.

Symptomatic EAH is much less common than asymptomatic EAH.  In one study of 2135 endurance athletes drawn from 8 events of varying distances, the incidence of symptomatic EAH was 1% (versus a 6% incidence of asymptomatic EAH in this study).  In another study of 669 161-km ultramarathon runners, there was only one case of symptomatic EAH, an incidence of under 0.1% (versus a 13% incidence of asymptomatic EAH in this study).  

Risk Factors

The most important risk factor for the development of EAH is the over-consumption of water, sports drink, or other fluids with electrolyte content lower than human plasma.  That’s right: guzzling sports drink DOES NOT, repeat DOES NOT prevent dangerous EAH from occurring, due to dilution of the plasma.  

Additional risk factors include being smaller in size and being slower (e.g. marathon times over 4 hours).  The use of NSAIDs (please see my extensive series of articles about NSAIDs and athletes to learn a lot more about this subject), also, at least theoretically, can be a risk factor for EAH by leading the kidneys to retain more water (by strengthening the effects of arginine vasopressin (AVP), which leads to more production of anti-diuretic hormone).  Interestingly, there is not much evidence about the “salty sweater” and relative risk of developing EAH.  

Mechanism of EAH

EAH is a result of dilution.  In this condition, the rate of increase in total body water exceeds the rate of removal of body water (through sweat, respiration, and urine) and the rate of replacement of sodium is inadequate to keep up with needs.  This mostly occurs through drinking too much water or other drinks, including sports drinks, that do not have as much electrolytes as human plasma. Another mechanism at play is decreased clearance of water from the kidneys due to heightened activity of the hormone, AVP.  This hormone is released by the pituitary gland in the brain and is usually responsive to the osmolality of the blood (changes in levels of sodium in the blood change the osmolality).  However, during sustained exercise, AVP production is responsive to other stimuli and (probably from teleological reasons) typically increases, which leads to heightened retention of water by the kidneys.  Interestingly, another source of extra water is the release of water, which had been bound to glucagon, when glucagon is consumed for energy.  

Most of the damage to the body, from EAH, is a result of water entering comparatively salty cells throughout the body (biological forces lead water to go to more salty areas).  The most important area affected by this phenomenon, by far, is the brain.  This leads to swelling of the brain.  In fatalities from EAH, typically the brain swelling becomes so severe that the brain stem is forced into a narrow opening at the base of the skull. This severely damages the brain stem and leads to death.

Treatment of EAH

Most of the treatment of EAH is beyond the scope of this article.  However, there are a few important concepts that medical personnel keep in mind when treating this condition.  The most important of these concepts is that giving routine fluids used for ill people, such as normal saline, can dilute the plasma more and make EAH, with associated brain swelling, worse. Therefore, hypertonic saline (saline with very high salt content) is the mainstay of treatment. The challenge, however, for medical personnel is that athletes can collapse for a number of reasons and, for most of them, normal saline is appropriate.  For example, in a study of over 1300 people who collapsed during Boston Marathon events between 2001 and 2008, only 5% had hyponatremia whereas 28% had hypernatremia.  Therefore, medical personnel need to rely on key aspects of the history to correctly make the diagnosis, such as sustained exercise and consumption of a lot of fluids, along with confusion and other evidence of brain swelling. Some organized events attempt to aid medical personnel by obtaining pre-race weights of athletes. An athlete with signs and symptoms of EAH who has gained weight or has lost less weight than can be expected for the circumstances of the race, is much more likely to, indeed, have EAH.  There has also been a call to have plasma sodium measuring devices available to medical personnel to truly establish the diagnosis.  

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Prevention of EAH

If you, the reader, remember nothing else from this article, please remember this:


The thirst mechanism of the human body is finely tuned to respond to small changes in osmolality.  Furthermore, it is difficult to accurately predict sweat rates and other aspects of fluid balance in all conditions, especially for slower athletes, so drinking to thirst is the most appropriate gauge of fluid needs for most athletes. In fact, a small study of 8 female marathon participants demonstrated that drinking to thirst did not lead to overhydration. The Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference (2015) states:

“Earlier published recommendations to begin drinking before thirst was largely meant for situations where sweating rates were high, above maximal rates of gastric emptying, and dehydration would rapidly accrue over time. Unfortunately, this advice has fostered the misconception that thirst is a poor guide to fluid replacement and has facilitated inadvertent overdrinking and pathological dilutional EAH.”

As mentioned previously, sports drinks have much less sodium than the serum.  Therefore, overdrinking sports drinks can lead to dangerous dilution of sodium and, therefore, EAH.  The take home message is that a sports drink will not protect you from developing EAH if you drink too much.

Another approach to preventing EAH is to provide fewer hydration stations at races.  For example, studies have shown that spacing fluid stations 20 km apart on the bike in an Ironman triathlon or 5 km apart in a stand-alone marathon has reduced or prevented EAH.  


Exercise-associated hyponatremia is common, dangerous, and preventable.  The most important concept to keep in mind to prevent EAH is to drink to thirst.  Sports drinks are great for a lot of reasons, but they do not prevent EAH.

Please be careful out there!


Hew-Butler T. Arginine vasopressin, fluid balance and exercise: is exercise-associated hyponatremia a disorder of arginine vasopressin secretion?  Sports Med. 2010 Jun;40(6):459-47

Hew-Butler T, Rosner M, Fowkes-Godek S, et al. Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Clin J Sport Med. 2015 Jul;25(4):303-320.

Rosner M. Preventing Deaths Due to Exercise-Associated Hyponatremia: The 2015 Consensus Guidelines. Clin J Sport Med. 2015 Jul;25(4):301-302.

Photo Credit: Gerard Fritz via Compfight cc

Recipe: Crock Pot Meat and Dairy-Free Pumpkin Chili


I was asked to participate in the Meatless Monday Night campaign, to find good alternatives to the meat and dairy-laden meals that so many of us consume along with football.  Sounds fun?  Well, I am not a cook…at all.  I enjoy feeding my family and food preparation is an interesting challenge, but I have had at least as many failures as successes.  My kids are fierce critics.  They will never let me forget the slow-cooked meal that featured chicken, olives, and mustard.  

I decided to participate in this campaign because I think it should be possible, even for kitchen hacks, to produce enjoyable meat and dairy-alternative meals.  As an endurance athlete, I am always looking for good protein sources that are not dependent upon meat and dairy.  Finally, as an allergist, I recommend restricted diets every day and it is really good for me to get some experience with dietary “finesse.”

After scouring the internet, I found a nice recipe for crock pot pumpkin chili (from Heather@Kissmybrocolli) and modified it to my needs and, anticipated, family tastes.  Here it is:


  • Soy crumbles, 24 oz
  • Medium onion, chopped
  • Minced garlic, 1 Tbsp
  • Red kidney beans, 15 oz
  • Great northern beans, 15 oz
  • Stewed tomatoes, 15 oz
  • Tomato sauce, 15 oz
  • Pumpkin purée, 15 oz
  • Cumin, 1 Tbsp
  • Chili powder, 2 tsp
  • Garlic powder, 2 tsp
  • Cinnamon, 1 ½ tsp
  • Paprika, 1 tsp
  • Cayenne, 1 tsp
  • Silk Almondmilk, 1 cup (the secret ingredient!)



  • Start by lightly browning the soy crumbles in a large skillet on medium-high heat.
  • Add onions and minced garlic and continue cooking until the soy crumbles are fully browned (this is subjective, since they start brown, already)
  • Add the soy crumble/onion/garlic mixture to a slow cooker and then add the other ingredients
  • Give it a good stir, then cook on high for 2-3 hours

I also made rice in my fancy rice cooker.  A Zojirushi.  I like it because it is idiot proof.

Preparation took me about 30 minutes, because I am slow.

 IMG_2503 IMG_2504

So, how did it turn out?  Honestly, I was nervous.  My kids were kind enough to mention the previous olive/mustard fiasco before digging in to the chili.  But, we all loved it.  Five out of five kids, my pregnant wife (which gives her a vote and a half), and me.  The chili was very mildly spicy with cinnamon overtones.  The Silk almond milk seemed to give it a more mellow flavor that appeared to suit everybody.  I do have one daughter who is obsessed with spicy food.  She did add hot sauce.  Several of us topped the chili with Fritos.

This is an easily modifiable, easy to prepare, meat and dairy-free meal that is accessible to both children and adults.

Check out additional meat and dairy-free recipes from the makers of Silk products at



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This conversation is sponsored by Silk. The opinions and text are all mine.

Ironman Muskoka 2015: Race Report


On August 30, 2015, I was fortunate to have participated in the inaugural Ironman Muskoka, in Ontario, Canada.  It was a very challenging event in a beautiful setting.  The following is a race report.  Just like all my race reports, my goal is not to discuss the boring aspects of my own performance, but to give a useful guide to future participants in this event.  


I live in the Chicago area.  While driving is an option from this area, my wife is pregnant and it just would be unfair to her.  I shipped my bike through Tribike Transport and we flew into the Toronto area.  Based upon the airport and traffic, it is a 2-3 hour drive to the site of the race. Canadian highways (at least those that we saw) are nicely maintained by US standards, but the signage at night is not very reflective and can be confusing.  Also, road signs indicate upcoming turns and there often is not a sign directly at the point of a turn.  Another interesting difference with US highways is the tollway, which runs charges after the fact by matching license plate numbers to credit cards.

Oh, and by the way, as a dense American it just didn’t occur to me that Canada, our good friend to the north, is a foreign country.  Therefore, I had not set up a data service for my cell phone and had to turn off roaming to save money.  This did become an issue at some points while driving, since a cell-phone map would have been really helpful.

Also, passports are required.  Make sure you obtain or update yours with a couple months to spare.


Deerhurst Resort

Deerhurst Resort

We decided to stay at Deerhurst Resort, which is the location of the race, including the packet pickup, swim start, transition area, and finish line.  This is very convenient, especially just before and just after the race, but VERY overpriced.  We paid prices that would be unsurprising for the Four Seasons in Chicago.  These high prices were not only for the room, but for meals at the hotel.  While much less convenient, there were plenty of other lodging options in the area and other dining options, as well.  For a quick meal, I recommend the Pita Pit.  For a nice breakfast (at half the price of the resort) I recommend Three Men and a Stove.  

We stayed in a room, at the bottom of a hill, literally 50 feet from the swim start.  The room was of decent size and clean, but certainly was not of high-end quality consummate with the price.

Our hotel did have a tiny trickle of WiFi which only appeared to work in our hotel room.  This aspect of the hotel was especially disappointing.

Packet Pickup and Expo:

The race was not very large (under 1300 registrants) and packet pickup was a breeze.  The expo was of good size and was adequate to get any last minute doodads necessary for a triathlon.

Other Pre-Race Comments:

The legendary 6x Kona Champion, Dave Scott, was at the race for the three days leading up to the event.  He led a number of free group clinics.  I participated in a group run 2 days before the race with Dave and about 20 other people.  What a thrill to be told by Dave Scott that my running form sucks (all though not in so many words)!  Seriously, he was gracious, energetic, and simply great.  He, and dozens of other current and professional triathletes, are amazing examples of why our sport is so cool.  Is there any other sport in which regular people can just go for a run with pros?

Also, there was a swim-up coffee and juice bar about 150 meters from the beach.  This was really fun the day before the race.

Bike and Gear Drop Off:

In all Ironman events, these things are handled in the day or two before the race.  This was easy, summarized in the race guide, and well-supported by volunteers.


At the time of writing this race report, it has been over a week since the race, and I am feeling nervous, again, just thinking about the start of the race. Wow.


Dropping off my special needs bag and getting marked.


The Swim:



This swim was a beach run-in to a comfortable (69 degrees Fahrenheit), clean lake.  The start was staggered according to anticipated swim time (under 60 minutes, 60 minutes to 70 minutes, and so on) and started at about 6:45 AM, instead of the traditional 7 AM.  This led to the obvious question: “does this mean that some people get more than 17 hours to complete the Ironman?”  But the last finisher was at approximately 16:50, so this never was an issue.



Mentally preparing and playing with my Garmin

The swim course was a clockwise rectangle with the out and back portions being very long and the connecting lengths being shorter.  The finish was actually inside a cove closer to the transition area than the swim start.  So, the return leg was the longest.  The buoys were always on the right and were yellow for the first half, orange at the turns, and dark red over the second half.  Since it was cloudy and I am color-blind, it was hard to see the buoys on the return leg of the swim.  I ended up following other swimmers more than sighting on buoys.  This is reflected in my GPS data, which shows much straighter lines of travel over the first half of the swim than the last.  Anyway, I was delighted with my swim time (1:09 and change).  


The first 100 meters of the race

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Some people felt that there was a helpful current headed toward the finish once we entered the small cove at the end.  I did not notice this (since I was being run over by, primarily, female, faster swimmers), but I did notice that the water was cooler at this point.  This felt great.

At the end of the swim, there were awesome volunteers helping people out of the water (it was slippery).  Then, there were wetsuit strippers who worked in teams of two.  I love these people!


Seaweed hanging off of me…


There is a considerable hill running up the left (from the perspective of the swim finish) side of the resort to get to the transition area.  I ran barefoot and I did not experience any sharp rocks, gravel, or other discomfort.

After reaching the top of the hill, race participants enter the hotel, run along a nice carpeted hallway, and enter his and her changing areas.  Volunteers help participants to find their seats (on and under which both the bike and run gear bags are stored), organize their gear, and then stuff and close the gear bags.  Essentially, my volunteer did everything for me but put on my helmet, sunglasses, socks, and shoes.

Participants then run back down the carpeted hallway and out to the bike racks. On the way to the bikes, I stopped at the sunscreen station, at which my wife was volunteering, and got a really healthy layer of sunscreen.  I then got my bike off the rack and headed into hilly hell…


About to get sunscreen blitzed.

The Bike:

This course is challenging and technical.  The total elevation gain is 2252 meters.  The course is a clockwise loop, completed twice, around an area of lakes.  To reach the loop, athletes ride about 5 miles from the transition area.  Even from the very start, there are hills and these become increasingly challenging up to about a third of the way through the loop.  I was constantly shifting gears and, truly, used every single gear on my bike.  I also dropped the chain once. The middle third of the loop is fast and feels like a net downhill.  Finally, the last third of the loop contains the two hardest hills of the loop.  These are painful the first time around and agonizing the second. After completing the two loops, participants return along the same 5 mile connecting “tail” from the beginning of the bike course.  This area was very surprisingly difficult at this point in the race.  Did they regrade the roads in the 6+ hours I was out there?



The bike course was simply beautiful.  It looks a lot like western Washington State, but without the mountains and with maples instead of alder and birch.  We rode along lovely lakes at several points and through a couple of cheering crowds.  Most of the ride was along residential roads, but there was some very smooth-feeling highway riding (with generally decent shoulders) in the second fifth or so of the loop.  Traffic was generally quite light and usually, but not entirely, respectful of race participants.  


I have raced Ironman Wisconsin, which has a total elevation gain similar to Ironman Muskoka.  I have also done the Horribly Hilly Hundreds in southwest Wisconsin, which is much more difficult than Muskoka.  Other famously hilly races I have done include Branson 70.3 and St. Croix 70.3, with its legendary “Beast.”  But I had a bike crash last year which led to surgery on a clavicle.  I also have had problems with muscle cramping on the bike.  So my approach to this bike course was pretty cautious.  Some of the downhills were just screaming fast and, yes, I chickened out and braked.  The wind also picked up over the second half of the bike and this led me to be further concerned about excess speed on downhills, since a crosswind could lead me to lose control.  This cost me in time, but my goal was to be able to finish the race, not break records.

My plan was to keep my power around 70% of my functional threshold power for the entire ride and I was passed quite often by other people powering up hills.  Oh, to be fast!  But I stuck to my plan, drank, ate, consumed salt, and conserved energy so that I would not be crushed by the run.  I finished in about 6:25 or so, which was about 10-15 minutes slower than expected.


When I dismounted off of my bike, a volunteer took my bike to rack it for me.  I then took off my cycling shoes and ran inside of the resort, again, to the changing rooms.  Once more, volunteers were present to really speed along the transition process.


Running from the T2 changing room. A blur!

The Run:

Okay, the bike was tough, so race organizers are going to even things out with a flat run, right? Very wrong!  The run course has a total gain of elevation of 608 meters and, by my count, 46 hills of various sizes.  That’s right, more than one hill per kilometer. Some of these hills are very steep.


The run course is an double out and back in which participants essentially travel from Deerhurst Resort to the Village of Huntsville (which is very quaint and cute), through and beyond the downtown area, then back to Deerhurst.  There is almost no tree cover at all and it did get a little warm and sunny at points (I think it reached 76 degrees).  The aid stations were, in a word, AWESOME.  Participants essentially have access to 24 aid stations during the race.  

I am at about 7:38 of this video, above. 

Another aspect of this race that I enjoyed was the metric system.  A marathon is 42.2 kilometers.  That means that there are a lot more markers of progress than in American races!


Embracing the suck

There are a lot of good runners who participate in triathlons and I am not one of them.  For some reason, my running performance has declined a lot over the last year.  Knowing this, I had been conservative on the bike and just planned to keep an even, easy pace during the run.  At no time was my heart rate going to get over zone 2.  I was careful to drink and eat and even took salt tablets during the run.  I continually ran, except walking through aid stations, for the first 8 miles, until I started to feel horrible.  I drank and ate extra and just slowed down until I started to feel better.  Then I ran-walked (more like walked-stumbled) the rest of the way.  Just after the halfway point, a guy to whom I was speaking before the swim start, Tom, tapped me on the shoulder and we shared the misery for the rest of the race.  Finally, another guy, Marcio, joined our slog for the last 10K.  These guys made it immeasurably more fun to get through the run.  My marathon performance simply stunk.  I was hoping for 4:45 and I achieved 6:02.  But I finished. This was an amazing feeling.  

Final Thoughts:

By any standards, this was a tough race.  There were 1298 registered participants and only 1056 finishers.  I think I had excellent training and a good approach, but my body just wasn’t able to respond as I had hoped.  But I have been through a lot over this last year.  18 months ago I had the bike crash, in an iron-distance race, that led to surgical reconstruction of my clavicle and recovery.  Then, almost exactly a year ago, in another iron-distance race, I passed out from heat stroke at mile 16 of the run.  So just finishing safe and well was a “win” for me.


REALLY happy to be done!

I have not spent nearly enough time mentioning the volunteers for this race.  These volunteers were simply the best volunteers I have encountered in ANY race, of any kind, in my 10+ year “career” as an amateur athlete.  There was uniform enthusiasm, energy, patience, and kindness throughout every aspect of the race from check-in before the race to check-out that night.  

Thank you, volunteers!  Thank you, Muskoka!  Thank you, Ironman!

Most of all, thank you, Jessica, my wife, for putting up with me on this journey.  I love you.


The Zen of Code Yellow: Voiding in Triathlon


Let me start this article by pointing out that I am an extremely clean person.  It is a long-standing joke in my family that I was destined from an early age to be a physician because of an obvious obsession with hygiene.

However, endurance racing, especially triathlon, is a different thing.  After having survived many dozens of less-than spotless port-a-potties before and, yuck, during races, I have learned to accept race-day hygiene as unavoidably separate from normal-life hygiene.

Another important issue is efficiency.  In triathlon we spend hours practicing transitions and buy expensive slip-on shoes, easy-entry cycling shoes, and other gear all in the interest of saving, truly, just a few seconds.  Well, how much time is “wasted” with a visit to the port-a-potty?  How much ill-will is generated when an athlete pulls over to the side of a race course, in a neighborhood, to void? Think about it.

This brings me to the slightly sensitive topic of this article: taking care of “business” during a race.  How does someone do it?  Are there accepted codes of behavior?  I will share my wisdom and perspective and you can decide for yourself.

The swim:

Is it OK?

It is never, ever, acceptable to void in a pool.  However, a lake or a river is an entirely different story.  As I learned at Med School at Duke: “dilution is the solution to pollution.”  The volume of water in a lake is simply too great for any amount of triathlete-derived urine to create unsanitary, or even noticeable, conditions.

How do you do it?

Just relax, slow down your swim stroke a little bit, and let it go.  With a little practice (in a lake or river, not a pool), you should be able to do this with minimal drop-off in the pace of your swim.


Don’t tell your significant other.  My wife will never touch my wetsuit now, even after I have thoroughly cleaned it…

The bike:

Is it OK?

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Generally speaking, voiding on the bike is just fine, with some caveats.  There is the possibility to create some spray behind you.  Therefore, always check behind before going Code Yellow. Also, this activity can, for some people, be a little public.  Public nudity/self exposure is not acceptable.

How do you do it?

This is much harder to do on the bike than during the swim. My suggestion is to find a portion of the race in which there is some degree of separation between you and other athletes and, especially, spectators.  Pedal a little harder, then sit up or stand, then relax.  It can take a few tries to find the Zen of Code Yellow, but it gets easier with practice.


Once you start Code Yellow, you will have a damp crotch.  If the weather is cool, this, by normal human reflex, may lead you to “go” again and again.  Be prepared. Also, since your bottom will be damp for, potentially, hours, you are at risk for nasty chafing: “baboon butt.”  If you plan to void on the bike, be very liberal with the Body Glide, or similar product, over broad areas of your nethers.

The run:

I have read accounts of professional triathletes who are able to achieve Code Yellow while running.  This is an expert-level accomplishment and, I am sorry to say, I have no guidance to give.  If you have information to offer, please share it in the “comments” to this article, so we can all learn from your gift.

The Zen of Code Yellow is, with some guidelines, an acceptable way to enhance your triathlon experience.  I hope that this information is entertaining and helpful to you.

Race and train safe and clean.

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Dim Mak: the Touch of Death. Is it real?


As a skeptical physician, I am slow to accept that this entertainment trope could be real.  But the Death Touch has found its way as a trope into so many popular movies (Executioners from Shaolin, 1977; Clan of the White Lotus, 1980; Bloodsport, 1988; and, as the ‘five point palm exploding heart technique” in Kill Bill Volume 1 and 2, 2003 and 2004) that it is almost as well accepted as the familiar trope of the knockout punch to the head (short of a severe injury, rather than being asleep for 30 minutes, most people would be briefly stunned and woozy, then really mad after being punched in the head).  

In the Touch of Death, practitioners achieve their goal either with one touch at a specific point or with a series of precise strikes.  There can be instant death or, for better cinema, the victim survives for a short period to time, aware of his or her fate.

There is a subtype of the Touch of Death that is non-lethal, The Paralyzer.  Any Star Trek fan is familiar with this, as Mr. Spock used this special technique (The Vulcan Nerve Pinch) to give his victims long, non-damaging naps.

Beyond entertainment, there are a number of historical and current practitioners of martial arts who have claimed knowledge of this closely guarded secret.

These practitioners take themselves very seriously and some have built a career surrounding teaching this mystical technique.

There are even Dim Mak masters who appear to be able to knock people down, non-lethally, without physically touching.

There are also websites that state that many of the special locations around the body that are used for healing purposes by practitioners of acupuncture and acupressure (“Stomach 7”, for instance) can also be exploited for the dark art of Dim Mak.

Here is a website selling charts of Dim Mak pressure points, complete with testimonials!

So, numerous popular movies and thousands of years of Chinese culture must be based on SOMETHING, right?

Well, this time, at least, the answer is a carefully qualified “yes.” The real Touch of Death is accidental and very tragic and is a condition called commotio cordis (Latin for “agitation of the heart”). Here is the definition of commotio cordis from a thorough review of the condition from the New England Journal of Medicine:

“Ventricular fibrillation and sudden death triggered by a blunt, nonpenetrating, and often innocent-appearing unintentional blow to the chest without damage to the ribs, sternum, or heart (and in the absence of underlying cardiovascular disease).”

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Commotio cordis has been described in the medical literature since the 18th century, but has been largely unrecognized as recently as the mid 1990s.  Since then, awareness of this condition has grown. Commotio cordis primarily affects children, adolescents, and young adults and most often occurs during participation in sports.  For example, about 50% of cases have been reported during such competitive sports as baseball, softball, ice hockey, football, and lacrosse, typically (but not always) after a blow to the chest delivered by the projectile used to play the game.  About 25% of cases occur during recreational sports, like playing catch or being struck by a snowball.  The remaining roughly 25% of cases have been reported during non-athletic activities.  Examples of these include blows to the chest from falling into a body of water, from an attempt to terminate hiccoughs, and from being struck by the head of a large pet dog.

Tragically, commotio cordis is usually fatal.  In the first decade of this century, the survival rate was only 35%.  However, it appears that survival rates have been increasing, as public awareness of this condition has risen, there has been more accessibility to automatic external defibrillators, and bystanders have been faster to initiate the “chain of survival” (call 911 or a similar rescue phone number, then start cardiopulmonary resuscitation, defibrillation, and other life support measures).

While this is not the theme of this article, there is an essential take-home point:

If you see someone collapse after a blow to the chest of any kind, DO NOT HESITATE TO RESPOND!

Commotio cordis, fortunately, can only occur under very narrow circumstances.  The blow must be directly over the heart and it must occur during an electrically vulnerable period of 10 to 20 milliseconds when inhomogeneous dispersion of repolarization is greatest.

This brings me to the second, essential, take-home point:

Commotio cordis is NOT a game or something that anyone should EVER try to induce!  

With regard to prevention of commotio cordis, a great deal of effort has been devoted to finding balls and pucks (projectiles) that are less dangerous but that will not change the nature of the games for which they are used.  Effort has also gone into designing appropriate chest protectors.  However, as of the time of the review that I have been using for this article (from 2010), suitable projectiles and chest protectors were not yet available.

So, how did commotio cordis become Dim Mak?

This question is open to speculation, but I think a pretty fair guess is that, during a sparring match, one ancient martial artist struck the other on the chest in the precise location and at the the precise moment to trigger commotio cordis.  Having no knowledge of cardiology, and with no visible damage to the chest, this tragic death was deemed to have been caused by a mystical ability: “The Touch of Death.”

To accentuate the dramatic aspect of this condition, and make it even more suitable to be used as a trope, 20% of victims remain physically active for a few seconds after the blow that caused commotio cordis, with the transient ability to continue to walk, run, throw a ball, or speak, for example.

To be clear, the Touch of Death, Dim Mak, is accidental and tragic, involves no chi or other mystical energy, cannot be taught to be consistently performed (nor should any attempts be made in this regard), and cannot be performed without physical contact.  Any other representation of Dim Mak is bullshido.

Please be safe.


Maron BJ and Estes III NAM, Commotio cordis. N Engl J Med 2010 Aug 18. 362(10):917-927.

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What Every Doctor Should Know About Athletes


Years ago I saw a patient in my practice who was in his early 60s.  This gentleman had been lifting heavy weights for years and had an amazing physique.  After I listened to his concerns and started to address them, he said to me “thanks for thinking about my medical problems and not being distracted by how I look.”  He felt the need to say this because many health care providers seemed, to this patient, to be so impressed by his appearance that they seemed to be unwilling to consider that he may truly have an illness.

In more than 17 years of practice I have found that the experience of this athlete is not uncommon.

This article is intended as a basic guide, for athletes and their health care providers, to some of the unique characteristics and concerns of athletes.  As an amateur athlete of modest ability, I will take the liberty of using the term “we” rather than “they”

We have unusual laboratory findings:

Athletes often demonstrate laboratory results that would appear abnormal in the sedentary population.  The most well-known of these is pseudoanemia.  Because, by conditioning, there is an increase in the volume of blood plasma, hemoglobin in the blood becomes diluted.  This can lead to hemoglobin levels commonly 0.5g/dl lower than “normal,” but sometimes up to 1g/dl lower than “normal.”  However, the total amount of hemoglobin in the blood, and, hence, the blood’s ability to carry oxygen, is not reduced.

Another common finding in athletes who are actively training and competing is a positive urine dip test for blood.  When the athlete’s urine is examined under a microscope, there is no blood. This finding on the dip test is a false positive because the dip test cannot differentiate between hemoglobin (in red blood cells) and myoglobin (which is released from muscles that are injured during exercise).

Similar to myoglobin in the urine, signs of muscle damage are also detectable in the blood after strenuous exercise.  These laboratory findings include elevated levels of myoglobin, creatine kinase, and aspartate aminotransferase (AST).  Since AST is usually considered a measure of liver function, an elevated level may be taken to indicate liver damage.

Our hearts are different:

Athletes often have big hearts in every sense of the word.  The physiologic version of our big hearts is called the “athlete’s heart.”  A review on this subject stated that, in roughly 50% of athletes, their training induces:

“some evidence of cardiac remodeling, which consist of alterations in ventricular chamber dimensions, including increased left and right ventricular and left atrial cavity size (and volume), associated with normal systolic and diastolic function.”

In addition, marked enlargement of the left ventricular chamber (greater than or equal to 60 mm) occurs in approximately 15% of highly trained athletes.

In addition to, or, more likely, a function of, our enlarged hearts, our hearts can have strange-looking electrical patterns, with approximately 40% of trained athletes demonstrating abnormalities on 12-lead electrocardiograms.

Our heart rates are often ridiculously low.  It is not unusual for highly trained male and female athletes to have resting heart rates in the 30s and 40s, respectively.  This low heart rate is reflective of the increased efficiency of the cardiovascular system.

But we can still have serious heart disease:

There is significant overlap diagnostically between a physiologically unsurprising athlete’s heart and the potentially life-threatening condition, hypertrophic cardiomyopathy.  Tragically, athletes die of this condition, as well as conduction abnormalities, coronary arteriosclerosis, and other heart abnormalities.  The bottom line is that an unusual heart finding in an athlete should lead to serious consideration given to having an evaluation by a cardiologist who has experience differentiating between an athlete’s heart and dangerous heart disease.

We obsess about “small” health concerns:

Athletes train for months and years.  For some athletes, training and racing is their full-time job. Often times, all of this training is directed toward a single race event.  For some events, like the Olympics, there is no second chance.  Either an athlete arrives and performs to his or her peak ability, or the years of intense training can be “wasted.”  Therefore, a “little cough” or sore throat, a sore joint, or even a blister in a bad spot can be extremely important to an athlete. Even if “minor” health concerns do not appear to be at a level that could affect performance, lingering doubt can be a factor.  It is extremely difficult for non-athletes to understand the degree of dedication it takes to reach a high  level of athletic prowess and the amount of emotional and physiologic stress an athlete experiences before and during an event.

This is, actually, an area in which non-athletic physicians and athletes can find common ground. Physicians often make huge sacrifices of time and social relationships to get through the education and training that is required to practice.  Just imagine, after years of stress and poor sleep, while your friends were going out to bars, buying homes, and starting families, not getting your medical diploma because you have a cold or a sore shoulder!

Fitness is not a hobby – athletes can’t just stop:

Aside from the loss of fitness (deconditioning) that occurs when athletes stop training, fitness is a lifestyle, a part of personal identity, and, for some, a career.  When an athlete sees a physician about a health concern that could affect his or her ability to participate in exercise, the expectation is that every effort will be made to help him or her to return to full participation.

We are prone to fads and experimentation:

When I first got into triathlon, small wheels and beam bikes were a trend.  Then there was barefoot running.  Similarly, nutritional trends (avoiding gluten or milk, taking antioxidants, taking other nutritional supplements, etc.), whether based on evidence or not are very attractive to athletes.  If an athlete believes that a legal nutritional intervention will lead to an improvement in performance, no matter how small, he or she may try it.  It is important for physicians to ask athletes if they are taking supplements and what, from the athletes’ perspectives, are the expected effects of these supplements. Physicians who treat athletes should have some familiarity with such supplements and should be able to offer constructive, evidence-based, guidance.

We fear aging and decrepitude:

We athletes understand, intellectually, that most of us will not be running marathons with our grandchildren, but we don’t know how we will deal emotionally with loss of fitness and activity. Every year I look at my performances and think to myself “is this the year I am starting to decline?”  Sadly, however, it is inevitable.  This is why, when a middle-aged athlete like me visits his physician, a gain of a couple pounds of weight or of 5 points of blood pressure can seem like a crushing defeat.

Many athletes doctor-shop:

Many athletes have limited budgets and time.  They will not put up with health care that they do not feel is helpful. If a brilliant physician gives excellent care in every regard, but is tone-deaf about the importance of peak fitness to patients who are athletes, those patients will seek care elsewhere.

Many of us have the same failings as everybody else:

I often find myself amazed when I read about a top athlete in his or her sport who is addicted to alcohol or drugs. These substances are so clearly detrimental to performance that it seems obvious that serious athletes would avoid them.  Sadly, this is not true. Physicians need to ask the same questions about smoking, drugs, and addiction of their chiseled patients who are athletes as they do of any other patient.

It is essential for physicians who treat athletes to understand their patient’s concerns, even if they seem trivial, and become fully engaged in becoming part of the athlete’s “team.”  This term, “team,” is not used trivially.  When an athlete trains or competes, there often is an entire team of people (coaches, physical therapists, massage therapists, dietitians, physicians, etc.) who has supported that athlete.

From a physician’s perspective, it’s fun to be part of a top athlete’s team. I saw a patient for follow-up recently who is a superb runner and has asthma.  He told me that he had recently broken the 4-minute mile.  I can’t run that fast.  Ever.  But I feel like my small contribution, as his asthma doctor, gave me a tiny piece of that achievement.


Maron BJ and Pelliccia A. Contemporary Reviews in Cardiovascular Medicine: The Heart of Trained Athletes, Cardiac Remodeling and the Risks of Sports, Including Sudden Death. Circulation 2006;114:1633-1644.

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Fieseler, C. What Runners Need to Know About Their Blood Test Results.

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Race Report: Ironman 70.3 Racine – 2015


On Sunday, July 19, 2015, I participated in the Racine 70.3.  This was the 11th race I have completed at this distance and the second time I have done Racine.  Like many other “Ironman 70.3”- brand races, it was run with a lot of professionalism.  The following is my race report. Like all race reports I do, I am not interested in promoting my athletic abilities (or lack thereof), but, rather, to provide information that will be helpful for you, as a future participant, as you plan your race.



Packet pickup was at the Racine Civic Center, which is just about a mile south of the transition and finish line areas for the race.  Packets were available on Friday afternoon and early evening and also on Saturday, at the odd time range of 9 AM to 4 PM. There is a mandatory drop-off of bikes at the transition area from noon to 5 PM on Saturday.  This means that those people who may have to work on Saturday morning are left with a potentially awkward 3 hour gap between mandatory check-in/packet pick up and mandatory bike drop-off.  However, I spoke with an athlete Sunday morning who was in just that situation.  She informed me that she asked for help from the race director. He took her bike from her on Saturday at 9 AM, brought it to the transition area, then texted her a photograph of her bike safely on the rack.  Great service!

I had some commitments on Saturday morning, so my wife, Jessica, and I arrived at the Civic Center at about 2 PM.  There is 2 dollar pay parking directly across the street.  Then there was a long line.  It took about 40 minutes to get everything  I think people after me waited even longer.  But there were over 2000 participants in the race and the Civic Center is not a huge building.  Race volunteers seemed to be on the ball.  I just don’t see how the line could have gone much faster in that structure.

The drive to the transition area took about 5 minutes, including parking.  I just walked my bike down a steep hill, racked it up, fidgeted with it to let it know I care, then left for home.  As I was dropping off the bike, there were tornado sirens.  Uh oh.  But it was still sunny.  By the time we had driven about 20 minutes, there was a torrential downpour and high winds.  I was certain that my bike, and 2000 others, would be blown off the racks and damaged (but this, fortunately, was not the case).

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Race Day

Transition opened on Sunday at 5 AM and closed at 6:30.  The race start was at 7 AM (my wave was at about 7:25) and it is about a mile walk from transition.  I like to get to races early, so I awoke at 3 AM and drove up from my house in Illinois, to park near transition at about 5:10. This is relevant because almost all of the parking for the race is on local side streets.  Later arrival times quickly translate into much longer walks before and after the race.  I was able to park about a block and a half away from transition.

When I got to transition, my bike was sitting on the rack exactly how I had left it.  I proceeded to get my area set up.  Then I gave my tires a squeeze.  The rear tire was very soft.  Oh no!  I borrowed a pump and inflated it.  This was at about 5:55 AM.  I then had to make a decision about replacing the inner tube or just hoping that temperature fluctuations and, perhaps, an unnoticed error with screwing down the valve the previous day was the reason for the soft tire. I decided that the inner tube was probably okay.  For the next 30 minutes, I was the idiot who kept squeezing his rear tire.  I never completely stopped worrying about this until nearly finishing the bike leg, but the tire remained inflated.


The transition area was a large rectangle with clearly-marked ranges of numbers at both ends of each row of racks.  It was an easy transition area to navigate.  A clever guy near me laid a strip of orange tape on the ground leading, perpendicularly, up to his area.  I wish I had thought of that.

Here is a photo of the pros setting up:


I walked unhurriedly to the race start and milled around with everybody else.  The water temperature was 60.6 degrees Fahrenheit (cold, not frigid), but the air temperature was about 78.  So I stepped out into the water, in my wetsuit, trying to find the right depth to balance the ambient air temperature and the water temperature.  For me, this depth was just over my waist.

This race is really groovy in that there is a decent pro purse ($50,000, I think).  Consequently, a lot of the world’s best male and female pros show up to race.  I love watching pro starts and this race was no exception. The pro men started at 7 AM and the pro women (along with a, trailing, challenged athlete) started next.

The Swim

The last time I did this race, the start was a run-in from the beach.  But, because of large-ish pebbles, the race organizers changed the start to waist-deep water.  This was true for both the pros and the amateurs.

The race course was exceedingly simple: swim eastward for a couple hundred meters, hook a right to swim southward along the Lake Michigan shoreline, then turn right again to swim another 150-200 meters westward to the finish gate.  Two years ago, the waves were so difficult that I had to alter my stroke and some people reported vomiting during the swim.  There were waves, again, this year, but not very challenging at all.

I followed my usual routine of swimming harder-than-race-pace until the first turn, then settling in.  Usually I look for a good draft but today I couldn’t find any that I liked. As it turns out, I couldn’t find a draft, perhaps, because I was having an exceptional swim (for me).  Two years ago, I had a brilliant swim (for me) at 38 minutes and change.  On this day, I finished in 33 minutes and three seconds.  Crazy fast, for me.


There is a long run-in from the beach to the corner of the transition area, then an additional run all the way from the south end of transition to the north end.  However, there were also wetsuit strippers, which makes up for almost anything.  I gave mine a big “thank you” and headed to my bike.  The tire was still inflated, so I was able to relax a little as I got the bike gear and headed out.

The Bike

The bike course starts with a steep hill right out of transition.  This is no problem with correct gearing.  But there was someone next to me who walked his bike uphill.  The rest of the bike course consisted of some easy rolling hills but, mostly, a flat course as we headed out of Racine and into rural Wisconsin.

In spite of the topographical apparent easiness of this course, I found it challenging two years ago and, again, in this race.  This is because there are extended sections of road that are just uncomfortable.  For example, a lot of the pavement in Racine, itself, was fairly chewed-up.  I understand that race organizers put “a ton” of fill in many of the gaps, and the orange warning markings were truly superb, but it was still rough.  Then there are areas of single-file in which I typically sit up to stay safe.  Unfortunately, other people choose to pass in these areas, leading me to be even more self-protective.  I had a bad crash last year, and I have five kids, so maybe I am more nervous on the bike than most people.

There were two or three course marshalls cruising around the course.  I am sure that it is really challenging to be a course marshall, but drafting was really rampant.  There was one funny wheel sucker in particular.  This was a tall guy in a fancy “I’m a cyclist” kit on a road bike.  He was drafting off of a much smaller woman who was on a tri bike.  He was truly inches from her rear wheel for as long as I could see him.  Clearly not a Sufferlandrian…

The volunteers at the three aid stations were fantastic.  This, by the way, was uniformly true for every volunteer with whom I interacted from start to finish at this race.  The hand-offs of fluids and other goodies were smooth and easy and I shouted “thank you” over and over.

Anyway, aside from having a decent ride, my goal was to set myself up well for the run by carefully taking in fluids, electrolytes, and calories and NOT cramping.  I achieved all of these goals, but was not quite as fast as I had hoped.


The bike ride ended going down the same steep hill with which it began.  After dismounting, I ran in with my bike, changed gear, took a deep breath, and ran out.  This was a very sunny day and there was a line of volunteers by the exit with sunscreen for race participants.

The Run

The run consists of a double out-and-back running along the shoreline north of the transition area and finish line.  On the run out, there are two significant hills (these are essentially access paths for beachgoers to get to and from the beach).  A photographer (apparently every year) camps out near the top of the steeper hill and gently mocks panting competitors.  Troll! But the rest of the course is pretty flat.  Much of the course has pretty vistas over Lake Michigan.  The inbound course does not go up and down the beach access paths, but, instead, goes through the Racine Zoo.  I looked and did not see any animals, but I think the race course only touched upon the periphery of the Zoo.

There were aid stations every mile and a half.  Each and every station was well-supplied and well “manned” with volunteers.  Choices included water, sports drink, cola, pretzels, sponges, ice, and energy gels.  There may have been other stuff that I have forgotten.

I am not a very good runner and when conditions are difficult, such as they were at this race, this is accentuated.  The temperature was in the low 80s and it was very humid.  This doesn’t sound so bad, except that Chicagoland has been very cool this summer.  So the weather felt much hotter.  Also, there is almost no shade on the run course.  Whine whine whine…

I drank a lot, put cold sponges down my front and back, dumped ice down my front and back, and ran with an ice cube in each hand.  I also consumed several gels and salt tablets. But mostly, I just kept going.  I really did try to run faster and I simply could not.  There were a lot of other athletes out there, including Team USA members and pros, who appeared to be struggling, as well.  But there were other people who just flew, including a really big guy who had tiny feet that just barely touched the ground as he cruised. Humbling.

The Finish

Naturally, I mentally prepared myself that the finish line was just beyond the turn-around point. The loudspeakers at this point were loud and clear.  But, sadly and painfully, the actual finish was about a tenth of a mile farther along.  Not much? Well, it felt like a lot.

I finally heaved myself over the finish line and my cute pregnant wife was waiting for me.  This finish line area was relatively uncrowded for a big race.  I got a hat, a medal, and a bottled water.  The food tent, which was very well staffed by volunteers, was just a short walk away. I got some food, sat down next to Jessica for a few minutes to recover, then got my gear and headed home.

My finish time was considerably slower than I had hoped (about 5:47), but I had given all I had that day.

This is a really nice, very well run “Ironman 70.3” – brand race.  I am sure I will do it again.


Exercise-Associated Muscle Cramps: Causes, Prevention, And Treatment


Aside from limited talent, one of the barriers I have encountered to quality training and to racing in triathlons has been exercise-associated muscle cramps (EAMC).  I am not alone.  It has been reported that 67% of triathletes complain of EAMC.

Years ago, at the start of my amateur career (in my 30s) as an endurance athlete, I completed the Marine Corps Marathon and got pretty dehydrated.  In the medical tent for IV fluids, I heard a guy shouting and screaming nearby.  He was having muscle cramps.  I remember thinking to myself, “what a whiner!”  Well, karma found me and has never let me out of sight.  EAMC are amazingly painful.  A muscle, which, inconveniently, is needed for an athletic activity, suddenly and without warning violently clenches and twitches.  It feels like the muscle is being ripped apart.  For me, EAMC episodes can last for 5-10 seconds, or up to 30 seconds, depending on how much I really need that muscle group for what I am doing.  In my scan of the internet it appears that the duration of my muscle cramps is pretty typical, but some people can experience cramps for up to 15 minutes.

It is possible to keep going in spite of EAMC.  I rode over 70 miles of an iron-distance triathlon’s bike course last year with repeated EAMC in my hip adductors, quads, hamstrings, and calves.  I did it, but I paid.  I ended up being unable to complete the rest of the race and I visited the local ER with a host of medical complications.  I still doubt that I have fully recovered from this experience.

Why do EAMC happen? Specifically, are there strategies that can be employed that will be helpful for me and you, the reader, to avoid and treat EAMC?

Why do exercise-associated muscle cramps happen?

The following discussion is given with the caveat that other medical conditions (such as diabetes and hypothyroidism), medications (such as diuretics and statins), and other medical causes of muscle cramping (such as nutritional deficiency) need to be considered first.

Most recent good reviews of EAMC present the two leading theories about the cause of this condition: dehydration/electrolyte imbalance and neuromuscular failure. These two theories are often presented as though they are in competition with each other.  This is a useful writing technique, but it may not be accurate

The dehydration/electrolyte imbalance concept seems obvious and simple.  Since the body cannot store enough water to make up for losses during exercise and since athletes do not or cannot ingest enough water to replace losses, EAMC follow from the sensitization of nerve terminals that occurs as a result of water depletion (and consequent electrolyte imbalances). When muscles contract, there is contracture of the interstitial space, as well, which leads to mechanical pressure on select motor nerve endings and, finally, EAMC.  Since there is more loss of fluids and electrolytes in hot and humid conditions, these conditions would be more likely to lead to EAMC.

But this theory is probably not adequate. For example, endurance athletes develop EAMC even in cold temperatures.  In a study of marathon runners, those who experienced EAMC did not have significantly different loss of plasma volume, blood volume, or body weight compared to non-sufferers of EAMC.  In a variety of studies, there was no difference between EAMC sufferers and non-sufferers in sweat rate and water/sodium losses and there was no correlation found between loss of body weight and EAMC.  In addition, water/electrolyte replacement (the treatment that would be predicted to prevent EAMC if this model were correct) has not been shown to prevent EAMC.

As a point of illustration, a small study was published in 2013 that examined cramp frequency with a high degree of dehydration.  In this study, of 10 male subjects, average age 24, exercised on a cycle ergometer until 5% loss of body mass or volitional exhaustion.  These subjects ended up losing an average of 4.7% of body mass.  At this level of dehydration, there was to change in cramp threshold frequency, cramp intensity, or the amplitude of EMG readings with cramps.  In other words, a loss of almost 5% of body mass (with loss of water and electrolytes) did not affect muscle cramps in this study.

Similar findings were described in a study of 43 participants in an ultramarathon.  About half of the athletes developed EAMC.  There were no significant differences between the cramp and non-cramp groups for post-race % change in body weight, blood volume, plasma volume, or red blood cell volume.  In the cramp group, the serum sodium concentration (after the race) was lower in the cramp group vs the non-cramp group (139.8 vs 142.3 respectively) and the serum magnesium was higher in the cramp group vs the non-cramp group (0.73 vs 0.67 respectively), but all of these values were within normal ranges.

In a study of 20 participants in an Ironman triathlon, there were no significant differences between the cramp and non-cramp groups in percent loss of body mass.  Interestingly, the cramp group had a lower post-race serum sodium of 140 vs 143 in the non-cramp group.  Once more, these values were within the normal range.  There were no other significant differences between post-race serum electrolytes, glucose, or hemoglobin.

As illustrated, above, available evidence does not support dehydration or electrolyte disturbance as an explanation for EAMC.  It is interesting, however, that post-race serum sodium concentrations were lower for cramp sufferers in two different extended endurance events.  I defer to those who know much more than me about cytology and the sodium-potassium channel.  However, my understanding is that the human body is designed to buffer large changes in electrolytes. Therefore, a three point difference in sodium in both ultramarathoners and triathletes may hold some significance, even though these values remain within the normal range.  Furthermore, perhaps it is not the absolute sodium concentration but the change over the course of an exercise event that can alter action potentials across cell surfaces.  [if you, the reader, have more knowledge about this line of reasoning, please share.  I have corrected articles in the past and I am happy to improve this one, as well.]

The mechanism for EAMC that is usually offered as an alternative to the fluid and electrolyte theory is the neuromuscular theory.  The proposed mechanism of this theory of EAMC has to do with neuromuscular overload and fatigue, which would lead to an imbalance between excitatory impulses from muscle spindles and inhibitory impulses from Golgi tendon organs. Without getting too technical, the bottom line is that, in this theory, there are less inhibitory impulses that would prevent the muscle in question from contracting.  So, the muscle contracts into an involuntary cramp.

There is some interesting evidence to support the neuromuscular theory.  Some of this evidence comes from studies in cats, which demonstrated that neuromuscular fatigue decreased the inhibitory impulses from the Golgi tendon organs and increased the excitatory activity of the muscle spindles.  In humans, EAMC occur more frequently after extended exercise (neuromuscular fatigue) than at the beginning of activity and also occurs more often when a muscle contracts while it is already shortened.  The observation about the contraction of already shortened muscles may fit the neuromuscular model because there is already less activity of the inhibitory Golgi tendon organs when a muscle is partially contracted. This would lead the muscle in question, upon further contraction, to be more vulnerable to cramping.

Another line of evidence supporting the neuromuscular theory is the benefit of stretching.  Of all the treatment options that have been suggested for EAMC, stretching is the one that has been shown to reliably be effective.  Stretching appears to work because it increases tension on the muscle’s tendon, which leads to activation of the Golgi tendon organs, an increase in inhibitory activity, and, therefore, a re-balance between inhibitory and excitatory impulses to the muscle in question.

There are a number of studies that appear to support the neuromuscular theory of EAMC.  One of these studies was a prospective cohort study of 49 participants in a 56 kilometer running race.  At the end of the event, 20 participants reported EAMC either during or within 6 hours of the event, while 29 reported no cramping.  The investigators reported that EAMC in this study was significantly associated with a past history of EAMC and a faster running time for the first 28 km of the race (in spite of being matched with non-crampers for personal best times).  EAMC in this study was not associated with age, body mass index, gender, recent and past personal best running times, reports of pre-race muscle pain, and reports of pre-race training (in terms of duration and frequency).

In another similar study of 209 Ironman triathletes, 43 reported EAMC and 166 did not.  While there were no differences between the two groups in pre- and post-race serum electrolyte concentrations and changes in body weight, EAMC was found to be associated with faster predicted and actual race times (in spite of similarly matched training and performance histories from subjects in the two groups).  Furthermore, a regression analysis showed that faster overall race time (and cycling time) and a history of EAMC within the subjects’ last 10 races were the only two independent risk factors for EAMC.

In a questionnaire-based study of 433 Ironman triathletes, 216 reported having had EAMC, while 217 did not.  The investigators in this study reported that the triathletes in the EAMC group were significantly taller and heavier, and predicted and had faster race times in spite of having similar past personal best times to the non-cramping group.  The EAMC group was also more likely to have had a past history of EAMC, a history of tendon and/or ligament injuries, and a positive family history for EAMC.

Taken together, the three trials summarized above indicate that poor pacing may play a large role in the development of EAMC.  This concept supports the model of neuromuscular overload and fatigue as the cause of EAMC.

It was also interesting to find an association, in the last study, with family history of EAMC.  This suggests, of course, that there may also be a genetic factor, entirely independent of fluids, electrolytes, and neuromuscular fatigue, that can predispose athletes to EAMC.  In fact, a study has recently demonstrated an association between the collagen gene COL5A1 and the development of EAMC.  In this study, the CC genotype of COL5A1 was significantly under-represented in the EAMC group vs the non-cramping group (11.1% vs 21.8%, respectively).

The neuromuscular model of EAMC does have some gaps.  For example, the electrical stimulation that was used in models of EAMC is not an exact match for real-life neuromuscular stimulation in humans.  Another point is that there does not appear to be a set level of fatigue at which EAMC occurs.  Instead, this level is probably unique to each athlete.  It is also unclear if the neuromuscular fatigue, in this model, is occurring peripherally (in the muscle) or centrally (in the spinal cord and brain). Indeed, a recent study demonstrated that static stretching does not lead to the autoinhibition of contraction that the Golgi tendon organ confers. In other words, this study showed that stretching before exercise does not affect the Golgi tendon organ.  Therefore, concluded the investigators of this study, if stretching before exercise reduces EAMC (which is unproven), the mechanism for this effect is not through inhibition of contraction by the Golgi tendon organ.

How to treat and prevent EAMC

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Since EAMC are so challenging, so prevalent, and so poorly understood, a remarkable variety of treatment options have been suggested.  The following is a list of many of the options I have found in the literature and on the internet:

  1. DMSO (dimethylsufloxide): I have used this chemical in the laboratory in the distant past and it SMELLS. The concept is to rub it over muscles that either are prone to spasming or have spasmed. DMSO is then, according to its proponents, absorbed into the muscle and the problems are solved.  The obvious weakness of this approach is that muscle spasms involve huge areas of muscle that can be very deep under the skin.  There is simply no way for a topical chemical to penetrate that amount of tissue and cause a beneficial effect.
  2. Biting/pinching a lip: The technique here is to pinch the upper lip for 20-30 seconds, but sometimes for up to 3 minutes.  It is supposed to work up to 90% of the time.  The first and most obvious weakness of this approach is that the lips are not connected to any muscles except the muscles surrounding the lips. There is no known nerve or chemical pathway that passes from the lips to any cramping muscle around the body.  The next point is that most muscle cramps do pass in well under 30 seconds. So, a muscle cramp would pass, just as reliably, by singing “Yankee Doodle Dandy.”  This is, I believe, an example of confirmation bias.
  3. Replacing calcium deficiency: a chiropractor named Dr. David Williams states, on his website, that: “I believe that 90% of muscle cramps are caused by calcium deficiency.” It would be truly great news if this were true.  That would mean that 90% of EAMC would be prevented simply by checking calcium levels and correcting deficiencies.  Unfortunately, Dr. Williams’ “I believe” is just that, a belief. He does not offer any scientific evidence.  This is because there is no scientific evidence to show that 90% of muscle cramps are caused by calcium deficiency.
  4. Quinine: Some sources suggest that tonic water, which contains a small amount of quinine, can be consumed before exercise to prevent cramping.  The rationale for this is that quinine is a mild muscle relaxant.  Because of safety issues (most importantly, the risk of thrombocytopenia, which is a dangerous drop in platelet counts that can lead to bleeding and other problems), the dose of quinine in tonic water is limited to 83 mg per liter and quinine, in larger doses, is no longer available by prescription in the U.S..  In a Cochrane Review of research about quinine and muscle cramps of any cause, the authors concluded: “Compared to placebo, quinine [at doses of 200 to 500 mg per day] significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected.” But note the dose required to achieve this effect is above the safe range.
  5. Pickle juice: A number of athletes and coaches have been advocating the consumption of pickle juice for years, apparently largely as a method to consume a lot of salt quickly. A study has shown that pickle juice can, in fact, help relieve EAMC.  In this study, when 1 mL per kg of body weight of pickle juice or deionized water was consumed immediately after the experimental induction of a muscle cramp in hypohydrated male subjects, the duration of the cramp was 49.1 seconds shorter for the group who consumed pickle juice (84.6 seconds vs 133.7 seconds) (please note, again, that these were experimentally-induced muscle cramps).  5 minutes after consumption of pickle juice or water, there was no change in plasma electrolyte levels.  Therefore, the investigators concluded that the improvement could not be explained by the restoration of fluids and electrolytes.  Instead, they postulated that the tart pickle juice initiated a neural reflex from the oropharyngeal region that led to inhibition of the alpha motor neurons of the cramping muscle.
  6. Mustard: Some athletes have used mustard in the same manner as pickle juice, with similar logic.  However, there is no published evidence to demonstrate a benefit.  In an interview in the November 2014 issue of Runner’s World magazine, investigator Kevin C. Miller, PhD (an investigator in the pickle juice trial, above) stated that he studied athletes consuming as much as ¾ of a cup of mustard with no relief of EAMC.
  7. Replacing fluids and electrolytes: Dehydration and electrolyte imbalances have been shown, per above, to not be a satisfactory explanation for EAMC.  However, there is no question that dehydrated athletes under-perform and are susceptible to serious or even life-threatening medical complications.  Therefore, even if the replacement of fluids and electrolytes does not prevent or relieve EAMC, it is strongly advocated for a number of other reasons.
  8. Eating bananas: This appears to be ineffective for a couple of reasons.  First of all, since the intended effect of bananas is to restore potassium, and since electrolyte imbalances do not appear to be the main cause of EAMC, consuming bananas would be predicted to be ineffective.  Furthermore, even if the restoration of potassium were important to EAMC, it takes 30-60 minutes for the potassium from bananas (depending upon how much is consumed) to get into the circulation.  This is a case of too little, too late.
  9. Stretching: This simple approach to muscle cramps addresses the most widely accepted mechanism for EAMC, muscle fatigue and misfiring. While stretching before exercise may or may not prevent EAMC, stretching immediately upon the onset of a muscle cramp can be very helpful.  I think of it as “re-calibrating” muscles.
  10. Contracting opposing muscles: Similar to the concept of stretching, this method is to take advantage of the reflexive relaxation of a muscle when the opposing one contracts (e.g. hamstrings relax when quadriceps are contracted).  Practically speaking, this technique appears to be reasonable and may be most useful when it is too painful to stretch a cramped muscle.
  11. Massage: at least for me, sometimes all I can do with a bad cramp is to rub it.  I have not found studies on this subject, but my impression is that massage would lead to some mild stretching (by compression) and relaxation of a cramped muscle, perhaps by activating the Golgi tendon organs.
  12. Exercise: plyometric and endurance. The concept here is to train neuromuscular units to operate more effectively with increasing levels of intensity. Explosive plyometric exercises are reasoned to be especially effective to make cramp-prone muscles more resistant to cramping.  But, to truly simulate race conditions (which, of course, is when an athlete would most want to avoid muscle cramps), intense endurance training is necessary.  As endurance fitness increases, muscles would be predicted to be less prone to cramp at a given level of intensity. Some experts state: “the better shape you are in, the less likely you are to cramp.” This statement, however, is not supported by the evidence, since athletes matched for fitness appeared to experience EAMC or not based upon their pacing and effort and not baseline fitness.  In other words, if an athlete trains and races within his or her abilities, he or she is less likely to experience muscle cramps.  But every race is a calculated gamble, in a sense.  If an athlete chooses to push his or her limits, then he or she needs to be prepared for muscle cramps.

Like many medical conditions, EAMC are possibly not a single medical condition (some researchers divide EAMC into “local” and “generalized,” for instance), but the endpoint of a variety of pathways.  In other words, different athletes may have different mechanisms leading to very similar-appearing EAMC.  [Incidentally, this is one big reason why the neighbor’s or friend’s anecdotal advice: “it worked for me” is often useless and sometimes harmful in dealing with medical conditions].

Recommendations (based on current research and informed expert opinion)  to prevent and treat EAMC

  • Train at race-intensity (or, conversely, race according to the level of ability that was attained in training).
  • Pace and use power carefully (learn, in training, how many “matches” are available to burn, then use them carefully).
  • Consider plyometric training of key muscle groups.
  • Pay attention to fluids and electrolytes.  I am not fully convinced that this is irrelevant to EAMC, but, even if it is, careful attention to hydration and electrolytes is critical to safe athletic performance.
  • Learn to recognize early warning signs of EAMC (for me it is a little tightness) and respond accordingly.
  • Learn how to train and race through cramps, and when to stop.
  • When cramps begin, STOP!! and stretch immediately. The seconds “wasted” for stretching will likely be more than gained back by the end of the race.
  • Along with stretching, consider corollary activities like flexing opposing muscles and massaging cramped muscles.
  • Consider drinking pickle juice once a cramp begins.  However, note that pickle juice has been shown to shorten the duration if cramps, but not prevent them.  Furthermore, the study involved consuming 1 mL per kg of body weight.  This means that a 70 kg person would have to consume  almost 2 1/2 ounces of pickle juice.  This must be tried in training first; some people’s stomachs cannot tolerate that much pickle juice.

Take it from me, EAMC are painful and frustrating. But, for many people, with careful attention to current medical research, EAMC can be managed.


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Braulick KW, Miller KC, Albrecht JM, et al. Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. Br J Sports Med. 2013 Jul;47(11):710-714.

El-Tawil S, Al Musa T, Valli H, et al. Quinine for muscle cramps. Cochrane Database Syst Rev. 2015 Apr 5;4:CD005044.

Kantarowski P, Hiller W, Garrett W. Cramping studies in 2600 endurance athletes. Med Sci Sports Exerc.1990;22:S104.

Maughan R, Exercise induced muscle cramp: a prospective biochemical study in marathon runners. J Sports Sci. 1986;4:31-34.

Miller KC and Burne JA. Golgi tendon organ reflex inhibition following manually applied acute static stretching. J Sports Sci. 2014;32(15):1491-1497.

Miller KC, Mack GW, Knight KL, et al. Reflex inhibition of electrically induced muscle cramps in hypohydrated humans. Med Sci Sports Exerc. 2010 May;42(5):953-961.

Miller KC, Stone MS, Huxel KC, et al. Exercise-associated muscle cramps: causes, treatment, and prevention. Sports Health. 2010 Jul;2(4):279-283.

O’Connell K, Posthumus M, Schwellnus MP, et al. Collagen genes and exercise-associated muscle cramping. Clin J Sport Med. 2013 Jan;23(1):64-69.

Schwellnus MP. Cause of exercise associated muscle cramps (EAMC) – altered neuromuscular control, dehydration or electrolyte depletion? Br J Sports Med. 2009 Jun;43(6):401-408.

Schwellnus MP, Allie S, Derman W, et al. Increased running speed and pre-race muscle damage as risk factors for exercise-associated muscle cramps in a 56 km ultra-marathon: a prospective cohort study. Br J Sports Med. 2011 Nov;45(14):1132-1136.

Schwellnus MP, Drew N, Collins M. Increased running speed and previous cramps rather than dehydration or serum sodium changes predict exercise-associated muscle cramping: a prospective cohort study in 2010 Ironman triathletes. Br J Sports Med. 2011 Jun;45(8):650-656.

Schwellnus MP, Nicol J, Laubscher R, et al. Serum electrolyte concentrations and hydration status are not associated with exercise associated muscle cramping (EAMC) in distance runners. Br J Sports Med. 2004 Aug;38(4):488-492.

Shang G, Collins M, Schwellnus MP. Factors associated with a self-reported history of exercise-associated muscle cramps in Ironman triathletes: a case-control study.  Clin J Sport Med. 2011 May;21(3):204-210.

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Mizuno Wave Enigma 5: Review


Mizuno is launching the fifth in their excellent Wave Enigma series this summer.  I had the good fortune of being asked to review the shoe before it reaches stores.

First, a few details about me as a runner.  I am 47 years old, 5’7″, 158 pounds.  I am mostly a triathlete, but I have finished 6 marathons and 14 half-marathons.  I am not a lifelong runner. In fact, I started running in my 30s.  Therefore, I do not have, and never will have, the smooth, beautiful gait of lifelong runners.  When I run, I try to keep a high cadence and midfoot strike, but I don’t always succeed.  I generally run 20-30 miles a week when I am not cranking up miles for a big event.

Enough about me, how about the shoes?

First of all, the Mizuno Wave Enigma 5 is an attractive shoe.  I got the blue men’s version with a bright yellow sole (called “Electric Blue Lemonade”). The shoes looked like they will run right out of the box.

When I first put the shoes on, they felt light, but also soft and springy.  The toe box is capacious, which is a nice feature for me.

But the real test is the run.

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My first run with the Mizuno Wave Enigma 5 was an 8 mile interval run on suburban streets.  I ran at paces ranging from 9:30 to 6:30 and got a good sense for the responsiveness of the shoes.  Unfortunately, I also found that the size 9 shoes I ordered were apparently sightly larger than the size to which I had become accustomed.  This led me to have hot soles after about 45 minutes because of sliding.  When I tightened the laces, I over-tightened them and my feet became numb.  This is NOT a fault of the shoe, but of the size I selected.  It is important to always try shoes on and take them for a test run before purchasing them.

Subsequently, I adjusted the laces and ran a 30 minute brick run (running immediately after cycling) on a gravel path, a 40 minute run along paths in a seaside community, and a 10 minute brick run in a seaside community.

These shoes are fun.  At slower paces, they gave good support and a sure strike.  I never felt wobbly.  The shoes are also quite light (10.9 ounces), for a well-cushioned shoe. But the area where these shoes really excelled was in acceleration.  They felt very smooth and the degree of responsiveness increased the faster I ran.

I am not a professional shoe reviewer and I do not have a lot of language to describe the different components of the shoe.  But I think I can explain the smoothness of the transition in speed and the nice responsiveness from the shoes as I ran faster.  Mizuno has a special type of cushioning called “u4ic-X” (pronounced euphoric-x).  It is light and responsive.  In addition to this feature, these shoes have the famous Mizuno “wave” technology, which is designed to give added stability to the running gait throughout the stride.

The Mizuno Wave Enigma 5 is a neutral shoe which is exceptionally light and responsive given its cushioning.  The cushioning, however, is not like running on pillows and some high-mileage runners may want to keep this in mind.  This shoe is an excellent choice for training and for racing distances from 5K to the marathon.