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Highschool Swimmer - Chronic Fatigue
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Here it goes the classic - medical advice over the random internet request. Yeah, i understand there are some risks, but would appreciate any guidance.

My high school daughter is a pretty good swimmer. She swims AA and AAA times for distance events. March started a spiral where she runs out of gas in the pool sooner every day. We have had all the classic blood work done and they come back pretty normal, with exception of one thyroid hormone that runs at the low edge of normal. Our family MD has no idea and referred her to a neurologist. Of course we can't get in there until the end of the month.

She eats well and sleeps 8-9 hours per night. She took three weeks off at the end of high school swim season and could not ramp back up to her previous work load. Now she is getting beat in distance swim by kids that are not free stylers. Lot of tears.

So, is a neurologist the right next step? Or does this seem more like a metabolism issue?

Who should we be seeing?

Thanks.
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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I don't know about the medical side, but how old is she? You've ruled out nutritional problems, I presume?

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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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What does she eat? How much?
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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I'd get a second opinion on the thyroid check. Depending on the lab and their readings, low end of normal could be on the wrong side of the bell curve with another check, i.e., if LabCorp did the first labwork, then retest at Quest Diagnostics. The numbers are based on sedentary, middle-aged females, not teenage athletes. Just a guess, but an experienced one ;-)

DFL > DNF > DNS
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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I swam back in the day and I had 3 daughters who swam too. What you describe is pretty common!. It is a tough sport.

She may not be eating and sleeping enough. Just "eating well" often doesn't cut it for adolescent who is training hard. At some point it does come down to calories in vs calories out, and balanced nutrition takes a second chair. "Oh my God, she eats like a horse and the grocery bills are killing me" is more what you should be feeling. If you have not done so already, you should start counting calories for a bit against training output to make sure she is getting enough. If she is doing high levels of swim training, it can actually can take some focused work for some kids to get enough calories.

8 - 9 hours a night is not really enough sleep for an adolescent who is training hard. (that is about the minimum recommended for non athlete teenagers . . .). And, "8-9" is fuzzy enough that it could really be 6-7. Sleep needs to be worked, not just happen.

It is also possible she is just not physically capable of handling her current workload. There is a continuum of how much work different people (i.e. swimmers) can handle. (the capacity to handle high levels of work over time is actually one of the big differentiators between elites and lower level athletes). She may actually go faster if she backs it down a bit. It does her no good to train over her head. Have you talked to her coaches?
Last edited by: STP: Jun 13, 17 5:46
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Does she also experience feeling sick a few hours or the day after a workout? This is the hallmark symptom of myalgic encephalomyelitis.

You may consider comparing her symptoms with the International Consensus Criteria for myalgic encephalomyelitis (ME): http://onlinelibrary.wiley.com/...96.2011.02428.x/full

Recent research indicates folks with ME are in a state of hypometabolism: http://www.pnas.org/...nt/113/37/E5472.full

Beware that because there is not a blood test yet for ME, and routine tests come back normal, there is a bias of some physicians to default diagnosis of depression (especially in a teen) and prescribe anti-depressants and stop pursuing the physiological symptoms. If a physician takes this approach, find a new physician.

25% of people with ME are house or bed bound.

Hopefully she has almost any thing else besides ME because there is virtually no research funding therefore little hope for treatment (unless you get cancer, because some cancer drugs help ME folks).

Advocating for research & treatment for Myalgic Encephalomyelitis (ME).
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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What are the chances it isn't mono?
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Not a medical expert

First thought is iron levels as it is pretty common, but the blood tests would show that. Even if iron was on the lower normal side I'd consider iron supplements or have her eat a steak every night. Better yet, teach her to hunt a deer and eat a ton of venison.

Best of luck!
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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x2 on the closer look at the thyroid - it's a no-brainer to rule that out with a young woman. if the bloods are generally normal (esp iron, etc), then yeah: maybe look to diet. lastly, consider checking where her head is at. is she burned out? overtrained? bummed out? no longer enjoying it?

talking to the coaches will also give you another data point. maybe she's been off in training? maybe the other girls have just lifted their games? at the risk of being indelicate, sometimes as adolescent girls 'develop,' they have big body changes fast that can have major impacts on their athletic performance.

good luck!

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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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If you've already checked iron, a mono spot test may be a good idea. Both low iron and mono are quite common (I've had both) and may be causing the symptoms you're daughter is experiencing. Both really throw training for a loop...mono much more so.
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Everything everybody else is saying here, and also maybe try skipping a practice or two a week. I never swam in college because I was too burned out by the end of high school. I'm pretty sure I could have eaten more, taken more days off, and slept more and that would have helped tons.

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Re: Highschool Swimmer - Chronic Fatigue [ZenTriBrett] [ In reply to ]
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This.

Also I hope OP isn't pushing her too hard. There have been Olympic-quality swimmers that burn out before getting the chance to earn a spot at OT's or swim in college.

"The person on top of the mountain didn't fall there." - unkown

also rule 5
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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I 2nd the mono/Epstein Barr test, it is what did me in a few times with the symptoms you presented..

Unfortunately you are in a rule it out phase with your daughter, so not a bad thing to get some advice here. Chronic fatigue can be so many things, you just have to go down the list until you hit the cause or causes, or take a break and hope it resolves itself in time..
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Are there any other symptoms besides failing to complete swim practice?

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Re: Highschool Swimmer - Chronic Fatigue [klehner] [ In reply to ]
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Ok, hitting a few high points here.

We already ruled out mono and Lyme disease. Should have put that in the original post. All standard blood work is good.

New round of blood work today, including complete thyroid panel and West Nile screen.

This a pretty driven kid. Her Mom and I hold her back from stuff. There is no pushing on our end.

Thanks, Alan
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Apparently not a high note, but...

Are there any other symptoms besides failing to complete swim practice?

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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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AEllswrt93 wrote:
Ok, hitting a few high points here.

We already ruled out mono and Lyme disease. Should have put that in the original post. All standard blood work is good.

New round of blood work today, including complete thyroid panel and West Nile screen.

This a pretty driven kid. Her Mom and I hold her back from stuff. There is no pushing on our end.

Thanks, Alan
Not to sound offensive or anything but also watch out for an eating disorder in the early stages (bulimia). Teen girl, driven, would not be uncommon.
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Re: Highschool Swimmer - Chronic Fatigue [klehner] [ In reply to ]
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She gets around fine during the day, though she wakes up tired.

No energy effects are seen in other activities, like a two mile bike ride or a mile walk-run.

Other than that, no other issues that her Mom and I can see.
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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How old is she/what year in HS? Whatever the diagnosis is, I hope its clear she needs a break.

No amount of sleep I got as a competitive HS swimmer was ever enough, especially paired with 5 am practice. I'd also echo the sentiments that "eating well" may not be enough. She needs to be eating A LOT. If some of it is healthy and nutritious great but supplement with cheeseburgers and fast food breakfast!
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Re: Highschool Swimmer - Chronic Fatigue [SallyShortyPnts] [ In reply to ]
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I second the recommendation to have another opinion on the thyroid number. I've dealt with hyper and hypothyroidism over the past few years, and even when my blood comes back in the defined normal range, its often not working for me.

As SallyShortyPnts said, these numbers are most commonly used to treat older women, not young athletic types (32 yr old male here). Low on the normal scale is way too low for me, and could be way too low for your daughter.

Only problem is that it can be hard to find a doctor that knows how to treat atypical thyroid patients. I've had my best luck seeing a naturalpath.
Last edited by: Lav: Jun 14, 17 7:59
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Did you get a ferritin test? This is not always part of the "standard blood work" and low ferritin levels might explain the symptoms you're describing. Not many family doctors or pediatricians have experience with teenagers who are training at high level, so this is something that's easy for them to miss. If this is the problem, iron supplements (and time) will fix it.

Here's a good article on the problem: http://www.runningwritings.com/...ficiency-anemia.html
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Re: Highschool Swimmer - Chronic Fatigue [smd] [ In reply to ]
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True Story:
A bunch of International Olympic swimmers were in town for a swim camp. Several local swimmers were invited to compete with the Olympians in an exhibition meet. The meet was advertised in the papers. A crowd came out to watch the event.

I was one of local swimmers that was invited.
What a great opportunity!!!

Except ......that it was my first day with mono.
No - I didn't yet know it was mono.
(The knowledge would have made it better).

I told my coach that I didn't feel well.
He just thought I was being a baby!

So I got to swim 1500 LCM with a field of international Olympians.

Awesome.....

I would have finished last anyway.
But I was at least 1.5 minutes slower than normal.
And all in front of crowd of national and international, coaches and swimmers.


The good thing is that I spent the next month mostly asleep.
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Been there, done that. Long journey for me (decades). Just sharing what helped me even though it may not help you. I had very similar thyroid labs. I take 10mg of Armor thyroid (straight from the animal, not synthetic) and this helped some but was not the whole story. If you read up on it, you will find out more about T3 and T4. You will find that it's a very tricky thing to get balanced. The rest of the story for me was diet. I had very nuanced but accumulative food sensitivities that were hindering me. I would get sleepy after eating. I lost strength. etc. Overall, I found it to be a long process of ruling-out different areas, forays away from traditional medicine, and lot's of patience. The most important thing to do is to start a detailed journal: diet, sleep, exercise. And get copies of her med records so she has them to reference as an adult.
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Seems like you are ruling most things out , so here is my 2 cents. If she wakes up tired, maybe a sleep study is in order. Have her evaluated for UARS (upper airway resistance syndrome) which is a little more subtle to detect than sleep apnea. And no, sleep apnea isn't a disease of only the overweight.
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Re: Highschool Swimmer - Chronic Fatigue [AEllswrt93] [ In reply to ]
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Ok, long slow path since June.

Recap:
Detailed iron panel - no sketchy results
Detailed thyroid panel - T4 a below normal low level
+ more to follow
+ MRI to investigate potential pituitary issue, no indication of trouble
Adrenal response test with no indication of troubles (she did not like the racing HR with that stuff in her system)
Negative for Lyme disease.
Negative for celiac.
She has picked up a dairy sensitivity in the last six months. She mostly avoids dairy now, occassionally taking Dairy Assist to allow pizza or ice cream. Roughly 2x per week.
Neurologist has no ideas and no recommendation for path forward.
Cleveland Clinic pediatric endocrinologist suggested that integrative medicine may be the next step.

She started on low dose of synthoid (levothyroxine 75 mg) seven weeks ago.
+ her Mom & I feel depression is reduced
+ her sleep pattern is better, she appears rested now in the morning
+ workout fatigue is not improved, last summer she wore us out biking and running in addition to the swim club
+ she describes it as "muscles feel tired all the time"
+ re-ran the thyroid panel last week, all markers within normal limits now, including T4.
+ I don't have the detailed results yet, conversationally, T4 is now above the low limit.
+ we asked for an increase in synthroid, the endocrinologist said no, it is too early

She keeps a food diary from time to time, but fights us on it tooth and nail. I see her with the herd of teenager swimmers a couple times a week. She is not the thinnest and not the heaviest.

I can't believe what a long road this has been with no real sign of an answer. I can't imagine how this must be for someone with a debilitating issue.

Any ideas out there?

Does anyone have any experience with this book? https://www.amazon.com/...lab+tests+are+normal

Thanks, Alan
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