My guest today is Jeff Sankoff. An emergency physician, ironman triathlete & podcast host of the Tri Doc podcast. His personal experiences with cramping and personal endeavours to find an explanation makes him the perfect guest for this topic. Today we cover: The proposed theories for muscle cramping The research history behind cramping The electrolyte imbalance vs neuromotor theory Potential risk factors like fitness levels, weather, terrain Potential treatment remedies The dangers of hyponatremia You can find Jeff and all his social media handles at his tri doc coaching website. Also make sure you listen to the Tri Doc Podcast If you would like to support the podcast, participate in Q&As & access bonus material sign up for $5US per month at our patreon page For Brodie's running blogs, podcast episodes and online courses visit our Run Smarter Website To follow the podcast joint the facebook group Becoming a smarter runner To find Brodie's running information on instagram @runsmarterseries
Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
:
On today's episode, the mystery of muscle cramping with Jeff Sankoff. Welcome to the Run Smarter podcast. The podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers and met with bad advice and- conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp. I am a physiotherapist, a former chronic injury sufferer, and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. This guest that I have today is the real deal. We have Jeff Sankoff. He is the host of the Tri-Doc podcast. I actually have a bit of an intro. Let me read it out. So Jeff Sankoff is an emergency physician and longtime triathlete with more than 50 finishes at 70.3 distance. He's done six Ironmans, six 70.3 World Championships over the last 20 years of his career in the sport. And since 2018, he's been producing the Tri-Doc podcast and coaches triathletes, runners, cyclists through his tri-doc coaching business. So he is a podcast host first and foremost, but he's also an emergency physician, which and, uh, iron man. So these combinations of things are just perfect for this topic. And as we dive into the interview, as soon as we dive into the interview, you'll see he'll be perfect for this topic around the mystery of muscle cramping and his experiences with muscle cramping. We dive into the potential causes for muscle cramping, the proposed theories and whether that holds up with the research and certain characteristics, certain risk factors and treatment, prevention, remedies. We talk about all this sort of stuff. We also dive into the condition of hyponatremia and how that can be quite dangerous for a runner. So we cover a lot and we've done really well. big mystery that it is. So we might get a little bit scientific through some parts of the podcast and I try my best and Jeff tries his best to bring it back to layman's terms and just the way that every recreational runner could understand. Hopefully we've done our job doing that. But nonetheless, if there is a couple of minutes of high technical stuff, it does get pulled back to layman's terms for the rest of the interview. So hopefully You take away a lot from this and we can solve the mystery or at least bring ourselves up to date with the mystery that is muscle cramping. So I also wanted to announce that over the past couple of weeks, I've worked hard at trying to deliver more value for the Patreon supporters. And there's always a link in the show notes if you want to join the Patreon family. But what was once the benefits of submitting any Q&A's, any questions to myself? or to expert guests that are on the podcast. I've now added a whole ton of other benefits, including once a month you'll get an episode early release, so you receive the episode before anyone else does. And also once a month you'll get an exclusive episode done by me. Yesterday I just finished recording a podcast episode for those Patreons and it's fantastic that I can address the people because I know the Patreons, I know them signing up so I can speak to them the hundreds and thousands of anonymous listeners that are listening now. So it was great. We talked about the early signs of running injuries, detecting the early signs of running injuries before it develops into something quite nasty and what we can do about it. And that was a topic that was voted by the Patreon. So once a month I do release a poll of what they want to hear more about. They can suggest their own what they want to hear more about. And then I release the exclusive episode. What are the bonus contents that I put in there? You receive a blog. Like I do release a blog once a week, but this is one with the full information with the full internal links and backlinks and all that sort of stuff. So you get a bit more of a visual component as well. The, if it does contain like some photos or some graphs and that sort of thing, it does contain it within the blog as well. So Patreons do receive that. So it's just. a way for me to say thanks for supporting the podcast. You also get more information, more exclusive information and bonus material in order for you to run Smarter. So it is only $5 per month. If you're interested, we've got that Patreon link and I'll welcome you into the group. We can say hi when we do our exclusive episodes and I can address you specifically. So fantastic that everyone's benefiting off that and that I can finally address a my little family. So thanks again once to those Patreon supporters so far. Yeah. So without further ado, let's bring on Jeff. Jeff Sankoff, welcome to the Run Smarter podcast. I'm pumped to have you on. Yeah. Let's start by saying welcome. Thanks Brody. It's great to be here. Okay. We've got the topic of today being the mystery of muscle cramping. And I think it's one that might not even affect a runner, but for some can be. hugely detrimental. So I want to start off with just asking, have you had any personal experiences with dealing with muscle cramps? Oh my gosh. Um, yeah. Uh, so I got into endurance sports late. Uh, I, after I finished my medical training and my residency and fellowship and everything else, I picked up first, just sort of a mixture of doing some weight training and some biking and running, and then a friend convinced me to try some endurance stuff. And. When I got into endurance sports, uh, I learned very quickly that I'm quite prone to cramping and have had issues with cramping throughout the almost 20 years that I've been in triathlon. And it has been an exercise in frustration, figuring out what causes them and how to manage with them. Yeah. It's gotta be tough to find that realization when you're partaking in Ironmans and triathlons, that's gotta be quite a bummer. Oh, it's incredible. It's undone so many a good race. I've had, I've lost podium spots. I was actually in first place of a race once first place overall, uh, with like less than half a kilometer to go and cramped. And that was the end of that. Uh, yeah, I've, I've really, it's, it's been a really, really frustrating experience. And I, like I said, I've, I've reached out to all kinds of scientists who work on cramping and read all kinds of literature on it. I, I've gotten to a point now where I have a pretty good sense of what, you know, triggers them for me. And I know how to manage them pretty well, but I still run into trouble, especially in certain kinds of races. Yeah. Well, you're the perfect guest to have on there, not only to experience it yourself, but like with your background, with the science and like delving into the research yourself, um, I'm super pumped to, to dive into it. So perhaps we start with, um, just the. I guess what's on everyone's mind. Can we have a definitive answer for why muscle cramps do occur? No, unfortunately not. Uh, this has been something that's been studied for well over a hundred years now, and there's been competing theories. There's a really a wealth of research on it. And right now I think we're at the point where there's two competing theories, but neither of them really. gives a satisfactory answer. My personal feeling, and again, this is based on my understanding of the literature and my own personal experience is that it's probably not something we're ever gonna be able to tie to one specific cause. I think that cramping is gonna end up being attributed to multifactorial underlying things, ideologies, and that certain things probably weigh more for certain individuals. but that there is no one thing that is going to be responsible for cramping in everybody or in anybody really. Yeah. And it would make sense because if you like, I started to ask a whole bunch of runners who do the same endurance sport under the same conditions, you'll say, you'll find those who are really prone to cramping and those who, um, like to say, if we propose a theory that it's due to dehydration or something like that, while we're all losing. sweat at the same rate and we might all have the same hydration levels yet. Some people cramp, some people don't. But in saying that sometimes like helping with hydration, helping with the electrolyte balance and that sort of thing can be a remedy for some people. And I've had a little look at the literature as well. And those two competing theories, like two main competing theories you say, do tend to weigh up with some like treatment can be effective for some if that might be the right mechanism for some. But yeah, I agree. It's really hard to, it's, it doesn't seem likely that a conclusion, an overall conclusion or an overall treatment remedy is going to be seen anytime soon. So perhaps we dive into characteristics or symptoms, the wide array of symptoms that could occur with someone who does encounter muscle cramping. And perhaps you might share your own experiences with that as well. Yeah, absolutely. And I want to just go back to something you said, which is, you know, people who are prone to cramping, there is no question that there are some people who just tend to be more prone to cramping than others. And there's probably genetics involved, although nobody has ever looked or identified a gene that's associated with it. But we definitely know that if you've experienced cramps in the past, you're much more likely to experience them again in the future, and that there are just subsets of people who are, for whatever reason, more likely to experience them. So that that's one of the risk factors. And then, you know, getting to your question as to what situations are more likely to cause cramping. Well, we know that longer events, those events that are done at a higher intensity for longer, so, uh, you know, ultra running marathons, those kinds of, well, actually I'll take back ultra running because ultra running is usually done at a lower intensity, but, uh, people who are training for a marathon and then go out and run the marathon at a higher effort than they would have. in their training are more likely to have problems with cramping. People who do an Ironman, same thing. If they're training for an Ironman and they train at a specific type of intensity and then they go out and run at a higher intensity, they're more likely to get into problems with cramping. So longer events done at higher intensities are more prone to have cramping. And interestingly, you mentioned dehydration and You know, a couple of things have been looked at repeatedly and found not to be associated with cramping. And one of them is temperature, even though temperature, uh, leads to more dehydration, more electrolyte loss for whatever reason, temperature has not been found to be an independent factor associated with cramping, uh, because we see cramping occur even in cold weather events. That being said, my own personal experience is I tend not to have cramps in cold weather events, even though I sweat and even though I lose, you know, hydration and electrolytes. So I personally believe the temperature probably plays a role, but there is no independent association just with temperature alone. So something else is going on that temperature might be playing a role in. The other issues that really are important in terms of determining cramping is if there's a lot of climbing. So we know that eccentric loading on muscles can be triggers for cramping. So it's not so much to going up, but it's actually when you're coming down, that can lead to cramps. And so rolling terrain can increase fatigue and cause that eccentric loading and result in cramping. So again, longer events, higher intensity, hotter temperatures, potentially, although it's not an independent risk factor and then variable terrain. Okay. Um, perhaps we discussed that article that looked at industrial workers. Like I was, when was it like a hundred years ago or something? They tested it. Yeah. And, um, in the 1920s looked at, yeah, I looked at workers in a factory, uh, and two factories. And then there was another one that was done on the building of the Hoover dam. And what they did is they, um, they, it was. interesting research methodology because nobody was consented. I guess this is before the time of informed consent. So they just took workers and they said, okay, you guys are prone to cramping working in this really hot environment, working 12 hours a day for really poor pay. So we're going to give half of you some water, we're going to give half of you some water with salt in it. And let's see what happens. And then they also compared it, I believe they had a control group that got nothing. And what they found is the people who got the water with salt tended to cramp much less and certainly significantly less than the people who got nothing. And from this, this led to that whole theory that it had to do with both dehydration, but more importantly, electrolyte loss. And that was the main theory that lasted for quite a long time and was the predominant theory, even though there was another theory that had been posited about the same time. And, but really didn't get as much popular sort of exposure until very recently. Yeah. And if we're talking about those multitude of factors, which you discussed before, if we take that population of industrial workers, they're, if they're working in hot conditions and they're working very long hours, they're just encountering, I guess, the type of muscle cramp that might be due to, um, electrolyte levels or dehydration, but they wouldn't be subject to those other factors you described, such as, um, eccentric loading or training at higher intensities. So potentially like that type of population, like the endurance athlete type population might be experiencing a different type of muscle cramp. You're absolutely correct. Uh, you know, exercise associated muscle cramps were not really investigated until the sixties. So all we had to go on at this point back in the 1920s was industrial, uh, related cramping. And so, you know, no question. I mean, it's still muscle cramping. It's still the same path of physiology. It's still this. uncontrolled contraction of a muscle. And, you know, at that point, the theory was that, you know, if you have an electrolyte imbalance across the membrane of either a nerve, or of the muscle cell itself, that you're going to get this depolarization leading to this unopposed muscle contraction. And the theory makes a lot of sense. But there are a lot of reasons. you know, down the road where, you know, further exploration has been done that, that sort of make us question, well, does it really make sense? Like, for example, we know there are a whole bunch of causes of hyponatremia where, or low levels of salt that we see in medical diseases. I mean, I see patients in the emergency department with low levels of salt all the time and none of them come in with cramps. So clearly, dehydration and salt loss. Yes, they may play a role, but while they, They clearly had something going on in this industrial study. And, you know, there, there have been some studies in exercise, associated muscle cramping, where electrolytes also have been shown to, to have some role. It's not the whole story. Yeah. And I wish all the theories that actually made sense in theory were, um, actually, you know, reflected in reality, but unfortunately that's not the case in science and especially when it comes to treating runners and running injuries. But I learned a long, I learned a long time ago that physiology, you know, it, it predicts much explains much, but predicts a little because, you know, it explains all kinds of things, but you can never actually take it to the bank. So it's probably worth mentioning the other theory that also came out of industry. And, uh, this, uh, was also introduced back in the 19 tens and it was because, uh, telegraphers, uh, used to get cramps in their hands. And, um, you know, they'd be sitting there and they'd be, you know, punching Morse code onto their telegraph machines. And invariably they'd start getting cramps in the small muscles of their hands. And at first people thought it had to do with fatigue, but then there was a competing theory that, uh, came about that thought that, you know, actually it doesn't seem like it's fatigue. It seems like it's more related to an imbalance in the impulses coming from the spinal cord. There seems to be excitatory nerve impulses coming to these muscles. and the normal inhibitory, uh, spot, uh, nerve impulses are, are not there. And this kind of like percolated through the literature for awhile, but it went away for a long time until it came back in kind of the 1980s where it was looked at again, and this time in the setting and the context of exercise associated muscle cramp, and that's really the competing theory that now is out there that there's this imbalance between excitatory and inhibitory nerve impulses coming from the spinal cord that leads to muscles, uh, contracting involuntarily and not being able to relax. Okay. And, um, in layman's terms, because we do have a lot of recreational runners listening to this, you would say that, um, when a nerve comes from the spinal cord to a certain muscle group, you have these excitatory, um, nerve paths that are neurons that activate that muscle and say, yes, we need to activate in regards to say if they're typing, yes, we need to activate our, um, our fingers in order to type away. But there's also these sort of competing impulses, which we call inhibitory, which would allow the muscle to relax. It's like a, an impulse that would switch off those muscles because as we activate, we also need to deactivate to relax, to move into a different position. We can't just hold like a, a muscle in like an excitatory state because then just curls up and actually has a cramp. And so. The idea being if it was, if we have the example of a telegraph person typing away, there is almost like a buildup or too much of those excitatory impulses and less and less and less of those inhibitory impulses to enable the muscle to relax and switch off. Is that right? That is exactly correct. And with runners, what they have shown is if, so in the tendons of our muscles, When you stretch a muscle, so you're in the course of running and the muscle is, I said stretch, what I really meant is stretch the tendon. So let me, when you're running and you contract the muscle, you actually put a stretch on a tendon. And within the tendon, there are these little sensors, kind of stretch sensors. When the sensor is stretched, it tells, there's this reflex loop through the spinal cord, which basically triggers an inhibit, inhibitory impulse. that tells the muscle to stop contracting. It's a protective thing to protect the tendon. So you think about how you are contracting your hamstring, for example, to bend the knee. So you're propelling yourself forward, you're lifting the foot off the ground and propelling yourself forward with a running step. And in so doing, you're contracting the hamstring and putting some stretch on the tendons that join the hamstring to the adjacent bones. this little stretch sensor within those tendons is triggered. And under normal circumstances, you get an inhibitory, uh, nerve impulse that comes back to the muscle and says, okay, we've contracted enough. We need to now relax a little bit. Well, they've shown that in certain circumstances, these normal inhibitory, uh, impulses just don't happen. And as a result, the muscle keeps contracting until you get a cramp and you get this unopposed excitatory impulse to the muscle to keep contracting until the muscle just has unopposed contraction and you end up developing this cramp. That's why you tend to always get a cramp when you're actually contracting the muscle. A muscle to get out of a cramp, you have to stretch the muscle out, but a muscle, a cramp will always start when you contract the muscle. And the belief is, is because you're getting this unopposed excitatory nerve impulse. that comes through the muscle and tells it to keep contracting and it just contracts continually into this little ball as you put it, which I think is an excellent description. So again, it's a little bit complicated. But those are the two prevailing theories that there's an electrolyte imbalance, or that there's this unopposed excitatory nerve impulse that is causing muscles to contract. Okay, could it be a combination of both? Like if we are losing or we have this imbalance of electrolytes plus this excitatory impulse, would that increase the likelihood of a muscle cramp? It's possible. You know, nobody's really done the research to, right now the research has been done to compare the two, but nobody's really done a lot of research looking to see if one contributes to the other. Most of the research on electrolytes at this point, is really kind of hard to tease apart because when you look at runners, so for example, they've done some great studies on marathons and ultra marathons and they take blood samples at the end of the race and they compare the electrolytes in those runners and they say, okay, well, which ones have you had cramps, for example, and they'll say, the ones who had cramps versus one who didn't have cramps, their electrolytes are really no different. So There's a lot of evidence that kind of like says, well, electrolytes are kind of, it's kind of hard to hang your hat on electrolytes. At the same time, it's really hard to know. It's hard to measure in the real world, these nerve impulses. You can only do it in a laboratory setting. So it's really hard to tease apart what's going on here. That's why I tend to believe that it's probably a combination of things going on. And I think that for different people, there's gonna be different. different reasons for why they cramp. I wouldn't be at all surprised if there are some people for whom electrolytes really are a predominant factor as to why they cramp and for other people it's going to be you know this imbalance in nerve impulses and maybe for some it's going to be an admixture of the two. Yeah it really is a mystery which is why I've got the mystery of muscle cramping in the title. Right. And like you said like if you think it's predominantly or if there is a factor of this electrolyte imbalance or hydration levels, then you probably would expect to see more muscle cramping in marathons or endurance events that it is warmer weather. But like you said, that's not necessarily the case. Right, right. And we are also seeing some research that suggests that, you know, better fitness, better fitness and better strength in affected muscle groups may, you know, prevent cramps, which would suggest again, that there's something going on at the, you know, the nervous system level, but you know, all of this is still, none of it has been, you know, a slam dunk. It's it all remains very much up in the air and very much, I'm going to use as many metaphors as I can, but, uh, you know, it's really, it's really, it's really hard to come down on this one way or the other. And that's why I really do think that people have to experiment and, you know, fortunately there are some treatments now that people can try. to try and identify what works for them and then seize on that and keep doing it. Yeah, and when you're talking about fitness levels, it kind of ties into what you explained before about people racing at higher intensities than what they are used to training at. And I guess if you're fitter and have higher fitness levels, then you're less likely to reach that or exceed that higher intensity. Um, to a greater amount, I can think of a couple of examples, like this fits exactly what I experienced because, um, I, I'm not one that's prone to muscle cramping, but I did get cramping in both of my calves, strangely enough. And I was during my first ever marathon. And it was during the last like 200, 300 meters when I decided just to kind of sprint for the end. And so that's four hours of running plus a little sprint to the end. There's no way I've. experienced that intensity in my training, in my life. And therefore both of my calves cramped and it was a strange experience because I've never experienced that sort of cramping before, but then also I've experienced cramping when swimming and it's usually in the little muscles in the feet and because I'm walking around in bare feet, I'm pushing off the, um, the surface and I'm pushing off like in between, um, uh, at the ends of the pools and Yeah, sometimes I can experience some, some cramping. And I think some people have experienced similar things around the feet when they're walking around in barefoot feet or doing something, I get people to do some foot exercises or some foot coordination exercises and they cramp straight away and that might indicate more the neuromuscular side of things that excitatory impulse theory. Um, have you encountered similar experiences? Absolutely. Yeah, absolutely. I'm a big proponent of, uh, you know, including strength training for my, my own athletes that I coach for, you know, endurance. And, and I, I incorporate a lot of strength training for myself and have found that has helped it. It hasn't, you know, obviated cramping altogether, but I find that when I go into a race and I've had a really good buildup of strength training, I feel like I'm in better shape and more likely to avoid cramping than if not. Um, and you know, I mean, over training for a race, and I don't mean over training as an overtraining syndrome. I mean, over training as in over training for the distance you're going to do, uh, sets you up well to have the strength and the fitness for the distance you actually race and is more likely to keep you out of that danger of It's one of these things where it's worth experimenting. If you are one of those people who's prone to cramping, you know, train for a longer distance and you're actually going to do and see if that doesn't help you get through the distance you're racing without getting into problems with cramps. Yeah. I couldn't help but observe as well. Like when I was studying at uni, I was a sports trainer for our Australian football league and couldn't help but notice that usually within, um, like pre-season games and pre-season training, everyone would be fine as soon as it's like round one, round two of the season, especially when it come to the fourth quarter, especially if it was a close game and people were working at higher intensities in the fourth quarter, people going down like flies with muscle cramps and that didn't seem to happen like halfway through the season or like towards the end of season when they had built up a certain level of fitness. So it's worth. It's interesting to think about and it's interesting to kind of put these patterns together that I've recognized throughout my years of observing sport. Yeah. It's a really great observation. And I completely agree. I think that, you know, you can make the argument and I'm sure the people who advocate for, you know, sodium as being the, you know, the, the issue here would say, well, you know, they're working harder, so they're sweating more, they're losing more sodium and that may be true. But again, I would argue that, you know, it's, it's just. one piece of the puzzle. And I think that, you know, taken together, uh, fatigue, uh, overexertion and, you know, pushing the limits and maybe a little bit of loss of sodium is probably all working together to conspire to lead to cramps. So, uh, you know, the, the fact that, the fact that we've seen, you know, some people really respond well to, to the, um, uh, the spicy, uh, shots or the, the pickle juice, uh, in the mouth is also, you know, pretty convincing evidence that this has something to do with the nervous system. Can you explain what's happening with the pickle juice? Because they don't actually drink it. Some of them swish it around the mouth and spit it out. So what's it actually what's happening there? Yeah. So there's these receptors in the mouth. TRP receptors is what they're called. And they're no they're also in the esophagus and or the tube that goes down to the stomach from the mouth. And basically you could stimulate these with different kinds of spices. And there are the, these spices are in pickle juice. And this was just one of these kind of like folk remedies that was stumbled upon. I could not find any history as to how it was stumbled upon, but whatever, it seems to be well known and it's been validated in the science. And there are commercial companies that have leveraged this, you know, making these mixtures of spicy drinks, usually with cinnamon and ginger and even like chili peppers. And basically by taking these into your mouth and swishing them around and you know, either swallowing or spitting them out, what you're doing is you're stimulating these TRP receptors. And what happens is these receptors activate a reflex that goes basically right to the spinal cord and activates inhibitory impulses down to the muscles. So it's a completely... like you're basically short circuiting the spinal cord in a way that nobody realized existed until you know, the pickle juice thing was investigated. So again, we go back to this notion that you know, cramping is caused by unopposed stimulation. Well, when you take these spicy things into your mouth, you basically short circuit the whole nervous system in a way to suddenly cause large sort of like outflow of inhibitory signals to the muscles and you can just stop cramps immediately. Now it's not been shown to work so much to prevent cramps, but it has been shown to work very effectively at least in a lot of people, not everyone, but in a lot of people it's been shown to work very effectively to just stop cramps completely once they come on. Yeah, which would make sense based on what you just described because you're short circuiting what's currently happening. And that wouldn't work if you're trying to take the preventative approach because there's not this mismatch of excitatory inhibitory impulses just yet. But yeah, that's swishing around or ingesting whatever might restore that imbalance per se. Yeah. And I mean, the interesting thing about it is, you know, people used to think, well, the pickle juice is really salty. So maybe it's working because it's replacing salt, but there's The pickle juice works instantaneously far quicker than, than you know, you would expect it to work if it was actually because of salt being replaced. And the other thing is, is my personal experience, and this is just an anecdote, so take it for what it's worth, is you know, I tend to feel when cramps are coming on, I usually have a little bit of warning. And I have found that if I use these products, I can prevent the cramps, you know, within the minute or two before they're gonna happen, because I can feel them coming on. So I'll usually, you know, take these products, switched them around in my mouth. And also at the same time, turn down the intensity of what I'm doing. It's almost always running, uh, turn down the run density a little bit. And I can feel that that. Cramping just dissipates. And then I can turn back the intensity back up again and I'm fine. So as much as you can't do it before the activity to prevent cramps, I have found that they can short circuit the cramps coming on, uh, within a minute or so of them, you know, of, of feeling them. They're coming. Okay. Has the. science shown any other treatment remedies or any other preventative strategies that might be effective? Well, you know, there's a lot of, again, it goes back to temperature. Uh, so, so certain things have been shown not to work. So stretching doesn't work. Um, you know, I mentioned strength training before, but you know, strength training, the jury is still out. Fitness doesn't seem to, you know, better fitness again, as much as I think it probably plays a role that has not been shown for sure. Um, one of the things, and like I said before, temperature is not an independent determinant of cramping. Still keeping cool definitely seems to help if you're, if you're performing a race in a hot environment, um, you know, when muscles become hot, they don't perform as efficiently. So keeping your body cool has, you know, definitely, uh, You know, it's something you desire because it allows you to perform more efficiently just for race goals, but it probably also has some role in mitigating cramps because again, I think that there's something going on here with temperature, even though the research doesn't totally bore it, bear it out. So if you cramp, for example, in your hamstrings, um, you know what I do, I, you know, we wear in triathlon, we wear tight fitting shorts. And so I'll actually put ice in my shorts and keep the ice on my hamstrings. And that will actually cool things down just locally. So, you know, there seems to be something about keeping cool in warmer environments. I know this is like, I'm just contradicting myself left and right here because I keep saying temperature isn't a thing and yet keep cool. But I don't know how else to say this except to say that, you know, it's so multifactorial and it's so independent for different people. And everybody I've spoken to who does get cramping in the heat seems to do a little bit better when they try to keep themselves cool. So. I throw that out there. In terms of other things that seem to work, you know, everybody who's looked at salt supplementation, it's, there's no real definite research that says, yes, that's a, that's a, you know, a winner. But again, if you're one of those people for whom, you know, salt seems to work, I am not gonna be the one to tell you not to do it. If you have had success taking salt supplementation, electrolytes of any kind, then it helps you. then you keep going because, uh, you know, if it works for you, then I'm all for it. Uh, a couple of things that have been looked at that don't work. You get magnesium doesn't seem to play a big role. Calcium also doesn't seem to play a big role. Okay. And going back to salts and like electrolyte intake, if someone is not a runner, but is like working like an industrial type of setting and losing a lot of high amounts of sweat and isn't really, you know, pushing their fitness levels at all and they're experiencing cramping, would you suggest like potentially some salt or electrolyte intake would be of benefit? Always, because you know, when we talk about hyponatremia, what we're really talking about is not so much salt loss, we're talking about excess water. The body does a great job of holding on to salt. Um, but what will happen is, is if you are in an environment where you're going to be sweating a lot, and then you're just drinking water, uh, your body will hold onto that water gladly, but it dilutes whatever sodium you have left. And so you end up getting hyponatremic because of that. So you have to be careful. And then we see this in athletes as well. Um, you know, sport induced hyponatremia was something that became very well known in the eighties and nineties. And we had critically ill because of it. And so there's been a much more, a much better understanding among athletes about the need to take salt at the same time. And even in industrial workers, we see that as well. There's a I think a pretty good understanding that you can't just take plain water, water is important, but there has to be some salt supplementation as well. Yeah, I remember my first ever running specific course that I attended in New Zealand and had the researcher J.F. Esquilier was taking the course and at the end of the last day, he started delving into this hyperdermatemia, which I'd never heard before and the importance of runners recognizing this and medical staff recognizing this for things like marathons, because it's more common than people think. And from my understanding, when it comes to the body's, um, fluid intake and, um, like the concentration levels, you have certain concentration of water, but then you have a certain concentration of other things like sodium and what might happen during a marathon, if you're sweating, yes, you are losing water within your sweat, but you're also losing salt within your sweat. And those who try and replace that and stay hydrated with only water is slowly changing that balance, that concentration within the body fluid, which can start reaching dangerous levels once there is a... a large concentration of water within that. Is that kind of what's going on? That's exactly what's going on. I mean, we call that basically it's water intoxication. So the sodium or really what we're interested in is part of salt. The chloride, which is the other part of salt is less important. So it's really the sodium that counts. and the kidneys do a remarkably efficient job of holding on to sodium. So as you become more and more dehydrated from sweating, even though you're losing some salt in the sweat, you're predominantly losing water and your kidneys will start holding onto sodium. Um, you know, resorbing sodium from the filtrate that would become urine, because when they hold onto sodium, that's the way your kidneys also hold onto water. Um, in medicine, we refer to sodium as the electrolyte that we are responsible for. So when I have a patient in the hospital, if their sodium is very elevated, I know that that's my fault because if their sodium became very elevated, what I've done is I've dehydrated them. Their kidney is holding on to all the sodium and I haven't given them enough water. And as a result of that, the sodium concentration got very high. Alternatively, if I've been giving them lots of free water, their sodium drops and that's my fault. So an athlete, who's out there, who's sweating and losing lots of water and losing some sodium as well. Their kidney starts holding on to all their sodium, but it's not gonna be able to compensate for the sodium they've lost. And so if they start drinking water alone, they dilute what sodium is left and they become hyponatremic. And that's the issue. And you hit the nail right on the head. So it's really athletes have to be very conscious of rehydrating and keeping themselves hydrated, but they have to do so while also replenishing. the sodium losses they've had. And it doesn't have to be a lot because as much as, you know, there are people out there who will, you know, say that, you know, sweat is a big thing. You got to be very careful of how much sodium you're losing in sweat. You know, what you're getting when you, you take nutrition on course and what you're getting with like, you know, most sport drink is usually sufficient to replace the losses over a couple of hours. It's only if you're going longer than that, then you have to start thinking about taking more. Okay. And what can we say about signs and symptoms warning signs? Because I'm picturing, this is when like a marathon, like a hot day on a marathon, a hot day for a marathon is where we start getting in danger because that's when we do lose a lot more sweat than usual. And because it is a hot day, if someone might be having similar symptoms and feeling really funny, a lot of people and emergency staff might. attribute that to like heat stroke or something and would try and keep them cool, give them the shade, but also give them a lot of water and which could further, um, exacerbate what this condition is. So are there ways that we can look at ourselves or look at another runner who might be slowly teetering towards this hyper-neutrinoic and, um, recognize what it is? It's really hard. Honestly, it's really tough. So, I mean, a big thing with like heat stroke and, you know, heat conditions You know, people who have heat stroke are going to be sweating profusely. They'll have a very thready pulse. So they'll, you know, they may have altered sensorium and that they're, they may be sort of confused and stuff, but if they're confused and they're in big trouble, if it's from the heat, uh, people who have hyponatremia, usually they're, you know, they're over hydrated and they're over hydrated with free water. So those people are usually, you know, not sweating profusely. They're usually confused. Uh, now this is if they're seriously hyponatremic, but you know, before that, the, the individual who's becoming hyponatremic probably won't know it. Um, there, there's really no great symptoms that are, that you can identify because it's really pretty silent. Uh, the big thing is other people around them are going to potentially notice that the person is off a little bit, uh, somewhat confused, certainly not performing the way they would normally. Um, but it's, it's tough. It's really, really tough to identify without actually having a suspicion for it and without having, you know, a blood test to actually see what the sodium level is fortunately, you know, the body takes care of itself and generally when somebody becomes hyponatremic, as long as they're not continuing to drink, their kidneys will pee off all of that extra water very quickly and sodium levels will come back to normal. pretty soon, but if they do get hyponatremic rapidly as can happen, um, they can become quite confused and can even lose consciousness. So, uh, yeah, it can be, it can be pretty serious. Fortunately, like I said, we just don't see it that often anymore because people are much more attuned to it. They take sports drinks, they do take sodium and, uh, it's much less of an issue than it used to be. Okay. And I think the message is just make sure you're, if you are experiencing like an endurance event, if it is hot, if you are losing a lot of sweats, then we just need to be mindful that we need to contain some sort of salt or like intake some sort of salts. And that might be in a variety of drinks and not just plain water. And absolutely. Yeah. If it does, I don't want to scare anyone, but if it does get too serious and you did say there's like loss of consciousness, what's actually going on and what, what are the real dangers if it does get too excessive. So as the salt level drops, you don't want to scare anyone, but this is gonna scare everyone. As the salt level drops, what happens is, is that the salt level in the salt concentration within the cells is now higher than it is in the blood. And the body does not like those kinds of imbalances. And so water will rush into the cells. in order to dilute the sodium within the cells so that it becomes the same concentration as it is in the blood. This causes swelling of the cells. This generally isn't a problem unless those cells are in a box that can't expand. So the skull is a box and the brain cells as they start to swell in order to, as water rushes into those cells, that's the problem. So you end up with swelling of the brain. and what we call cerebral edema. And that's what causes loss of consciousness. As I said, that's pretty severe. We tend not to see that anymore. I mean, you have to get really profoundly hyponatremic really quickly in order for that to happen. And for the most part, you know, that's not likely for an athlete to get into. More commonly, an athlete is going to just become confused. Um, you know, not able to keep their balance, things like that. And then they will come to people's attention before they get into serious trouble. Yeah. And it's good to hear that you're experiencing as well in your field that the awareness is there now and it's less likely that it does encounter or yeah. We do have the right practices in place, which is awesome. As we're wrapping up now, um, are there any final takeaways or final thoughts that you want to share with runners? around cramping or around hyponatremia that we haven't covered? I think the big thing is, is just like I said early on, uh, you know, if you're one of those people who's prone to cramping, try different strategies. Uh, think hard about what kinds of situations you've had cramps in and think about, uh, you know, could it have been because of salt because you were sweating a lot and, and you really didn't replace salts, you know, enough. Uh, it could have been potentially because you were pushing it too hard and therefore maybe it was a nervous system thing and, and just try the different remedies that are out there. I mean, try electrolyte replacement, try the, you know, the different shots of spicy liquids or even the pickle juice shots that are out there. Um, and see if they help, uh, you know, experimentation is really the best way to find out what works for you. And. don't despair because it can be beaten, maybe not a hundred percent, but it definitely doesn't have to ruin all of your races all of the time. And as far as hyponatremia goes, you know, like I said, it's potentially dangerous, but fortunately not seen nearly as commonly as it used to be. And, uh, just make sure that, uh, you know, you, you train, you race the way you train, which is to say, you know, when you train, you take in, you know, liquids that contain salt so that when you race, you do the same thing. Okay. And is there any, well, in regards to like your social media platforms and your podcast as well, um, can you tell people about where you're most active and where they can go to find out more about you? Yeah, absolutely. So I have a coaching website, which is a tridoccoaching.com, uh, where you'll find links to most of my social media, but I'm on Instagram at tridoccoaching, all one word. Uh, I'm on Facebook where, uh, I can be found under both try doc coaching and the try doc podcast. I have pages for both. And, uh, the podcast is, uh, found on all of the usual platforms, Apple, uh, podcasts as well as stitcher Spotify. And it's the tri doc one word TRI DOC podcast. Fantastic. And I love the, the level of research and the lengths that you go to, to educate the listeners, the. people who read your content, listen to your podcast as well. And I think this episode in itself, if someone's listening now and has loved the, the level of detail and the level of science, then you're going to love the try dot podcast as well, because this is just like an example of like a lot of your podcasts that you already have on there, this is exactly what happens. You go through the science, you go through the research, and then you come up with this kind of like non-biased, um, opinion and you know, it's. open to interpretation a lot of the times as research usually is. And if those, like, if someone's listened to, um, science of ultra, that's one of the podcasts that sort of, um, is very similar to yours. And, uh, that's what I thought of as soon as I started listening to a lot of your episodes. And so I want to say thanks for the level and links that you go to, to deliver such informative content. And, um, a lot of athletes need to hear a lot of the topics that you have to say. So, um, thanks for doing your research and thanks for providing that information. Well, thank you. It's been a pleasure to have this kind of conversation and it's great to talk to runners because that's a third of what we do actually after all. Thanks for listening to another episode of the Run Smarter podcast. I hope you can see the impact this content has on your future running. If you appreciate the mission this podcast is creating, it would mean a lot to me if you submit a rating and review. If you want to continue expanding your knowledge. please subscribe to the podcast and get instant notifications when a new episode comes out. If you want to learn quicker, then join our Facebook group by searching the podcast title. If you want to take your learning to the next step, including injury prevention principles, injury specific insights, and modules to boost your running performance, then head to our website by searching runsmarter.online and jump into our Run Smarter Online course. Once again, thank you for listening and becoming a Run Smarter Scholar. And remember, knowledge is power.