Kind of random, but have you looked into lymes disease?

(Quote) "+ 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"(Quote)

I know that she is a very driven girl but have you broached the idea that perhaps, if she didn't bike and run at all, then she would have more energy for swimming???

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"Anyone can be who they want to be IF they have the HUNGER and the DRIVE."

Has she seen a cardiologist? How is her resting heart rate?

I was a competitive swimmer all through college. Overtrained was my first thought. However, that's gone on too long now. I'd have a workup done with a cardiologist. Muscles feeling "tired" can often be attributed to an elevated heart rate.

Hows the protein in her diet? Lots of red meat, eggs?

Poor kiddo.

We have checked and she appears to be negative for Lyme disease.

No issues with joint swelling or stiffness.

Biking has ceased.

Her running has dropped off a lot. Last fall she could run a 23 minute CC 5k. This season her best has been 26:30. She likes the CC team a lot and has been reluctant to drop it entirely.

Her resting heart rate ranges from 60-70 bom. That would be high for a slowtwitcher, but for a 15 year old?

We started a morning evening log of heart rate. I don't have it with me at the moment.

Thanks, Alan

I'm in the cardiology consult camp. No history of heart problems as a child? ASD/vsd? Maybe needs a blood gas analysis...check her room air oxygen saturation...she may have a shunt causing her to have mixed arterial/venous blood...that would be very indicative of being tired all the time. Also does she snore? You're the one who knows her and her body habitus...OSA (sleep apnea) is not always directly related to being obese. Many skinny people snore, which leads to decreased oxygen levels at night and people wake up tires after a nights sleep...long term osa can lead to a multitude of other things such as afib...I'm guessing her rythem is normal?

Just some food for thought.

Hi Alan, I recently went through a version of this so maybe I can give you an idea or two. Boilerplate IANAD. In fact two separate doctors told me my thyroid was fine and I just needed an antidepressant. I don't remember my muscles being tired but I was depressed, overall fatigued, not sleeping well, experiencing mild gut issues, and couldn't lose weight.

- I'm glad to hear she's getting complete thyroid panels. BUT, if she's still on the low end of normal, she might benefit from a dosage increase or switching from Synthroid to Naturethroid if her T3 is also borderline low. She is a teenage athlete and not a sedentary, middle-aged woman and her medication should be adjusted accordingly. Also, your doctor is right in that 7 weeks is too early to really detect a change in thyroid levels from supplementation. I usually go once every 3 months for blood testing when I need an adjustment.
- Have you checked her vitamin and electrolyte levels? My D was in the toilet. I also discovered my serotonin levels were in the toilet.
- Is she on an oral contraceptive? That could interact poorly with thyroid meds.
- Has she been tested for food allergies? If she's allergic to dairy or gluten, for example, that can inhibit absorption of nutrients, which could help explain why she's so tired. Gluten intolerance/celiac and hypothyroidism often go hand in hand as they're both autoimmune disorders (I have both).
- My new doc also wanted me to get rid of things like fluoride toothpaste, which supposedly can inhibit autoimmune function, but the jury is still out on that.
- Does she get enough protein and iron?

I haven't read that book, but I can definitely relate. Please keep us updated. Hoping you find an answer soon.

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http://mediocremultisport.blogspot.com

Did not know she was running CC, thought she was just running for cross-training. I can def see how she wouldn't want to give it up if she enjoys it. I run with my dogs every day at a park near my house and about 2 days/wk HS CC teams are running there, and they def seem to enjoy the camaraderie of their shared suffering.

Don't know what else to say except that the problem could still be overtraining. IIRC you mentioned she took 3 wks off back in the spring but, if she is really OT'd, she needs more like 3 months off. OT happened to me when I was 15/16 and it took me a good 6 months of rest to get over it; the "rest" should be qualified by saying i played a lot of tennis during those months, and my tennis did not seem to be affected at all. Came back to swimming and was doing my previous times in about 3 months.

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"Anyone can be who they want to be IF they have the HUNGER and the DRIVE."

In medicine there is a saying that goes, common things are common. May sound stupid, but many seem to feel the need to look for a obscure diagnoses when the answer lies in the description of the problem. The most obvious issue is overtraining (reaching), fatigue. Many young swimmers work off a general training plan designed for an entire team or for parts of a team, that leaves little room for rest and recovery. As you know, once fatigue develops, but is ignored, it starts to snowball. The first thing that a MD should be doing is advising rest, and more rest. Trying to train through this is not advisable. Completing a work-up with a Neurologist may be indicated if the examining physician found signs that need further specialized work-up. I've had the opportunity to treat and a few swimmers with similar scenarios, that generally resolved with rest. Fatigue, leading burnout is not uncommon in young swimmers. Sounds like she rested, and expected to return to her regular performance levels too soon. Probably needs to shut it down for a while, and slowly return to activity in a monitored way. Not jumping back in and trying to compete. Comparing her current times to past times should be put on hold until she has a few months under her belt of training and feeling healthy.

I was pursuing my pro card in triathlon when I came down with Lyme Disease last year. I didn't develop chronic fatigue, but I did develop joint pain and swelling. Many people I know develop chronic fatigue caused by Lyme Disease. Chronic fatigue seems to present more in women than men.

You should look into it because the standard ELISA test that she took is falsely negative 50% of the time. It only tests one particular strain of borrelia burgdorferi and there are many strains. I tested negative with the standard blood tests as well - Standard ELISA and Standard Western Blot test. I even presented with the typical bullseye rash, which only occurs ~50% of the time in Lyme infections.

You should ask your GP to test her using a Western Blot test from Igenex. They are a lab specializing in tick borne infections in California. - I was positive on this test. If your GP isn't familiar or can't run the test for some reason, find a local "Lyme Literate" Doctor.

Now here is my story regarding fatigue that may help... For years I have dealt with fatigue issues and many years ago they found I had suffered from glandular fever so probably explains a period I felt fatigued but nothing as to why I was constantly dealing with it later in life. It varied sometimes worse than others and I learnt to adapt my Ironman training around it times of day I felt more energy or not but each year I was getting stronger I seemed to deal with it more and more until last year I did a massive few months leading into Kona and my numbers were looking amazing (for me) but during my big block of training mentally everything just felt harder due to a fatigue feeling and I had to go deeper just to get the numbers I was chasing and I started to constantly feel tired again. Kona it all just fell apart. I went and had everything tested thyroid, adrenals, hormones, you name it again and found I had adrenal fatigue. I started taking herbal adrenal support had some time off and started training again for Ironman New Zealand in March but never felt back to levels I had been. It all fell apart during the race again and I suffered my first DNF for an IM. I had some time off and tried to start training again but went through the worst cases of fatigue I have ever had including two weeks where to get off the couch was an effort. I found a doctors clinic that specialise in finding issues rather than a general practitioner and went with all the results I already had. They ran a few more tests and basically found nothing substantial. My nutritionist I saw after Kona who had all the original tests requested to find I was suffering adrenal fatigue suggested I send a faecal sample off to be analysed and found I have a parasite dientamoeba fragilis of which symptoms include fatigue, adrenal fatigue and the constant headaches I have been dealing with for years in the evening. They also ran a bioscreen on my gut and found I was low in e.coli collform should be 70-90% make up and I was 0.18% and on the inverse high in strepococcus should be less than 5% and I was 94%. High strep symptoms are also fatigue.

So I tried the herbal route to get rid of the parasite but it was still there so I have just hit it with antibiotics and the herbal at the same time and have just finished. I feel mentally more alert, the headaches have gone and my energy levels feel on the up so I will see how goes. To get the gut balance correct lowering strep and increasing e.coli takes time so I will have another analysis in a few months time. If you have tried everything else then my suggestion to you is to see a natropath and organise to faecal sample sent off to check for parasites and a bioscreen. Of all the doctors I went to in the end they said we don't know and never even made that suggestion and most don't seem to even understand what a good make up is.

If you are still lost to the cause as I was then I suggest give this a try. I hope it helps...

seconding what others have said about sleep. Does she have early AM practices? Teenagers get their best sleep during the day.

If you don't get a response from desert dude, PM him and see if he has some ideas. He's coached HS swimmers before and is super smart.

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maybe she's born with it, maybe it's chlorine
If you're injured and need some sympathy, PM me and I'm very happy to write back.
disclaimer: PhD not MD

What you say is wise. What is there to lose by taking a few solid months off of swimming vs endless visits to doctors and tests and feeling superfrustrated at not seeming to be any answers. IMHO vague symptoms like this more often than not eventually get better no matter what is done and whatever was "tried" at the time gets the credit. The Lyme tests from Imegex are not recognized by CDC (many false positives good business model for them) and many "lyme literate" docs will give a diagnosis of lyme disease for symptoms that could be from almost anything.

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They constantly try to escape from the darkness outside and within
Dreaming of systems so perfect that no one will need to be good T.S. Eliot

Thanks for adding this. Test ferritin for sure. Not just iron. Many docs won't do this unless you specifically ask. Full iron panel should be done.

I'll share my experience:

I was a year round swimmer and towards the end of HS, I began experiencing a host of odd auto-immune symptoms: incredible fatigue, random arthritic swelling of joints, pressure in my head, flu like symptoms, severe sinus congestion and severe allergies to chlorine only when I was fatigued, but no allergies when I was feeling relatively healthy. I left HS with a 4:13 400y IM time that made D2 possible, but I wanted to try for D1, so I took a year off after HS, worked on a farm and trained extensively for swimming. I had good spells during that period of time, but then my symptoms began becoming more constant and remained relatively constant for more than 3 years while I attended college, not swimming competitively or competing much at all. I saw different medical specialists about once a week during the time. I had periods where I could barely get out of bed for two months at a time, and my white blood cell count was incredibly low. But all tests came back negative. I was told I had chronic fatigue syndrome.Subsequently, my research at the time was in autoimmune diseases.

I did have one nurse practitioner suggest it was stress. This was in the late '90's, so stress as the culprit was near laughable in the medical community at that time, outside of Sheldon Cohen's work on stress in the mid '80's. The nurse practitioner was correct. But, it wasn't day to day stress, or academic pressure, or athletic pressure related stress, but stress as measured by the adverse childhood experienced survey tool. That research is readily available today, but it did not exist in the late '90's. The correlation between those stresses and autoimmune responses and mediating epigenetic methylation is compelling.

Without tossing out a bunch of research papers, here's a quick summary. I did a quick google search and found this accessible article on a site I'm not familiar with, but I fact checked the article and the content is legitimate and it provides links to the original research being referenced: https://alignlife.com/...lt-chronic-disease-3

With your daughter's situation and with so many tests coming back negative. I suggest looking into this. Have a medical professional administer the ACE survey tool with your daughter with your daughter having the opportunity to keep the answers of the survey kept between her and the medical professional so that she can answer the survey honestly. It's a start and easy enough of an avenue to explore.

On a positive note, I've been healthy now for 15 years, train at a pretty high level and consider my swim fitness to be greater now that when I was in HS; I'm working towards a phd; I have allergies and some autoimmune symptoms still, but I just control my environment and diet enough to where it doesn't interfere with my athletics, school or personal life. I suggest not seeing things in the ACE outcomes like addiction, and more dire outcomes and ruling it out. The health outcomes, seeing your daughter's situation, are why I suggest exploring this direction, and because I personally did not and have not suffered from addiction or the more dire outcomes; I was/am a bit of an over achiever but it was my health that suffered as a result of the ACE's, not necessarily my behavior. I scored a 6 on the ACE survey.

http://citeseerx.ist.psu.edu/...ep=rep1&type=pdf

http://slideplayer.com/slide/3963592/

http://slideplayer.com/slide/4764873/

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wovebike.com | Wove on instagram

len wrote:

What you say is wise. What is there to lose by taking a few solid months off of swimming vs endless visits to doctors and tests and feeling superfrustrated at not seeming to be any answers. IMHO vague symptoms like this more often than not eventually get better no matter what is done and whatever was "tried" at the time gets the credit. The Lyme tests from Imegex are not recognized by CDC (many false positives good business model for them) and many "lyme literate" docs will give a diagnosis of lyme disease for symptoms that could be from almost anything.

Hi Len,

Do you have any evidence to substantiate your claim? I said in my previous post that the CDC recognized two tier tests (elisa + western blot) are notoriously inaccurate. In fact, they are so inaccurate that many states on the East Coast have laws in place that require your doctor to tell you that you still could have Lyme even if you test negative. Look up Dr. Neil Spector - A top Duke University Oncologist. He was negative so many times that by the time he eventually tested positive, he had irreversible heart damage and required a heart transplant.

I agree that doctors of all sorts, not just Lyme Literate physicians can make mis-diagnoses. It happens all the time. I was mis-diagnosed as having reactive arthritis by a rheumatologist with 40 years of experience.

I suggest you read this article with information from 6 studies, which shows how poor the standard elisa and western blot tests are. It also explains the qualifications of Igenex.... not "Imegex":

https://www.lymedisease.org/lymepolicywonk-the-cdc-the-fda-and-lyme-disease-lab-tests-two-tiered-tests-igenex-the-c6-and-the-new-culture-test-2/


Again. I was negative on BOTH standard tests when I had a bullseye rash. A bullseye rash is enough to make a clinical diagnosis of lyme disease without the two tiered test. This is N=1, but it paints a picture for sure.


Let me be clear: I didn't even know what Lyme Disease was before I got it. I live in the Seattle area and you never hear about it out here. I am simply stating the facts of the matter.

Please listen to tri Doc here. I am also a physician.
The law of parsimony says that the simplest explanation of phenomena is usually the best.
Most likely is that she is simply overtrained. . Her workload exceeded her ability to recover. Better nutrition, sleep, recovery (ie massage) can help but will not make up for the fact she probably needs a huge break from training.
That said it would still be worthwhile to simultaneously look for common medical problems like mono, subclinical hypohyperthyroid problems, anemia, depression, cardiac issues .... Deep overtraining can make her susceptible to some of these conditions as well.
If she still has symptoms after 3-4 months of rest, go ahead and look for the zebras.

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I second this. Hb doesnt cut it. You need to test ferritin as well as free iron. A low ferritin causes workout fatigue and inability to work at any reasonable intensity.

Howevery, burnout is most likely. Swim teams build a scheduled that is supposed to make a maximum amount of people perform better, not make every athlete perform at their best.

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Endurance coach | Physiotherapist (primary care) | Bikefitter | Swede

I had multiple normal results of routine blood work, yet had mutli-system dysfunction and could only walk up 1 flight of stairs at a time, or walk 10 minutes slowly on flat ground, so fairly disabled.

I had to send my blood to Germany (Armin Lab) to test for enteroviruses as my (Canadian) health care system stopped doing enteroviral testing in the early 90s.

Turns out I have coxsackie B, one of about 100 enteroviruses. Polio is probably the best known disease caused by enteroviruses.

Just as an FYI, Dr Hyde maintains that the difference between poliomyelitis and myalgic encephalomyelitis (ME) is the location of the enteroviral infection on the spinal cord. With polio the infection site is further down the spinal cord causing paralysis, with ME it is higher up, closer to the brainstem.

http://www.millionsmissingcanada.ca/.../Hyde-What-is-ME.pdf

From what I understand, Dr Chia in the US tests and treats enteroviral infections: http://www.enterovirusfoundation.org/directors.shtml

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Advocating for research & treatment for Myalgic Encephalomyelitis (ME).
http://www.meaction.net/about/what-is-me/

"Suck it up, Buttercup"
(me, to myself, every day)

One thing that I haven't seen covered here: asthma. Tired all the time and inability to recover could both be a result of reduced oxygen intake. And when it develops in fit athletes, it can be hard to catch, because you don't think "asthma" if the person isn't having an obvious attack.

It's worth checking it out.

Hi. I'm sorry to hear about your daughter. It's hard to watch such a decline and not be able to find a definitive answer.

A swimmer on my daughters' club team was diagnosed with Postural Orthostatic Tachechardia Syndrome (POTS). It falls under the Dysautonomia umbrella. Teenage girl with tons of energy and huge success in the pool went from barely able to make it though a day at school. It was disheartening to watch. Luckily, the diagnosis came quickly, but follow through at the Mayo clinic and the timeline for improvement was lengthy. She is now back to the pool and running cross country as well.

I wish her and your family the best in finding an answer.

I struggled with an "on the low side of normal" thyroid for about 15 years before someone finally diagnosed Hashimoto's. That's certainly one to watch, and to be reasonably aggressive with. Some people just don't feel good at the low end of normal values.

I only saw one mention of Vitamin D through the thread - if the endo hasn't checked that, it's well worth it. That seems so small (it's just a vitamin, right?!), but if she's low on that the difference will be night and day. I take 50,000 units of D a week just to get to the normal range, so it can be more than a gummy-vitamin-in-the-morning treatment for some people.

You also didn't talk about the quality of her sleep; do you notice her snoring at all, or stopping breathing while she's sleeping? She's not the typical candidate for sleep apnea, but if something is preventing her from getting solid, restful sleep it doesn't matter how many hours she is in bed. That would certainly cause chronic fatigue on top of her training load.

correct. Rest comes first, then look for zebras/quaggas.

not in HS but managed to overtrain myself aged early 20s, needed six months complete rest and a course of immunoglobulin to recover..
diagnosed with CFS in the early 30s but I believe that was related to the aftereffects of cerebral malaria, rather than training as such. haven't recovered yet from that..

+1.
my son lost 10lbs last swim season, on 5000 calories/day.. we are mailing him care packages this year, to provide extra calories..