The Decision – Microfracture Surgery

I’ve written more about injuries on my blog lately than I have about training or science or life.  It’s just where I am in life.  As I write this my left leg is strapped into a continuous passive movement (CPM) machine repeatedly going from 0 to 90 and back to 0 degrees.  My leg is restless and as I glance at my stopwatch I see that I still have another 90 minutes of this tortured mechanical and completely painless hell before I reach my goal of 6 hours for the day.  Its repetitive and boring, but yet it is also necessary, like much of recovering from an injury and subsequent surgery.

Continuous Passive Movement in the Tiny Home with Coffee and Charlie

As I prepared for surgery my scientific curiosity came out in full force.  After my first MRI, I consumed every article with the words chondromalacia (cartilage loss) and surgery (see pubmed list here).  It drove me crazy that there is not a single best practice for this and that each of the approaches have major drawbacks.  We can edit out genetic diseases, but can’t fix cartilage?

My injury (likely) began in Scotland (skip ahead a bit if you want injury only details).  After a successful return to competitive ultras culminated with a win at the Highland Fling I decided I needed to explore more of the Highlands before attending the wedding of friends from my Copenhagen days which brought me to the northern parts of the UK.  Northern it was, and in May that meant some significant snow at a mere 1200 ft.  My goal was a 25-mile loop through the Highlands, but 4 miles in I was post-holing and moving at an inexcusably slow pace, which I vowed to make up for with aggressive downhill running.  Poor strategy and my unnecessary risk taking resulted in a nasty fall in which I hit my left knee directly on the granite rock.  With a gash of several inches that required stitches, but only received steri strips (I should have taken advantage of government healthcare), my running on the trip was done.  In the back of my head I was worried that I did something more than cosmetic.  That sort of impact does not go unpunished.

Fast forward several months and an occasional twinge would make its way into my left knee, but never pain and never causing me to stop.  The fall semester of 2015, my first teaching, I was so busy it was near impossible to train.  That spring I vowed to run “the” local race and managed to get into decent shape, but would be stopped from full on training by a left knee pain that would come on following a hard training session and reliable disappear with a few days off.  My race suffered from the same pain a mile from the top of the climb.  Time off, a trip to Europe, and then retraining again while in Boston I suffered the same pain, stopping me from running and lingering into my walks for several days.

Upon returning to Boise I vowed to get the problem fixed.  My MRI showed an area of bone-on-bone contact where a small (2-3 mm) area of cartilage was gone.  I also may have had some meniscus damage.  The surgeon recommended no surgery.  I could walk with no pain and could run 30-40 minutes several times a week pain free.  As I already knew from my own research there were no good options and no guarantees.  Lifestyle adjustments first.  I’d become a more rounded endurance athlete – I could live without running as long as hiking, biking, and new sports like skiing and climbing could fill the gap.

My first MRI following a 9 mile run meant to make the area angry showed a small cartilage defect and swelling of the bone.

I suffered again through a busy Fall and managed to break my thumb cross country skiing.  But my knee was still hurting and not just running.  Skiing and walking seemed to aggravate it. WTF, was I just overly sensitive?  It was getting to the point of altering my quality of life.  A weekend backpacking trip pain-free was impossible and so come spring I sought additional opinions.  All opinions (those with an MD behind their name and mine) agreed that surgery was a good option and that the best of the worst options was a microfracture surgery.

So why are they all bad options? Well we are born with a specific type of cartilage in our joints called articular cartilage.  This cartilage has the property of being able to absorb repetitive shock and allows gliding of bones against each other for the entirety of our lives, hopefully.  Those that suffer osteoarthritis (bone arthritis) have degraded cartilage that causes the bones to rub, become inflamed and painful.  Surgery for osteoarthritis is a temporary fix with many of moving on to total knee replacements, replacing the idea of restoring cartilage with removing the cartilage (and bone) altogether.  This is because the cartilage that they restore or replace is not identical to what was loss in one way or another. However, I’m optimistic that I am not headed down that path yet as my injury lacks the pathology of arthritis and was trauma induced.  Yet, the science is NOT super clear on this either!!!

Note that my cartilage lesion is in the 4-5mm range. So much smaller than the typical 1-5 cm.

Mircofracture surgery has been around for nearly 30 years with mixed success.  In a not uncommon story in modern medicine it was developed before scientists really understood why it works (you only have to show that something works for it to get approved by the FDA).  Now we know it works because of stem cells, or more specifically mesemchymal stem cells that are located in bone marrow.  The surgeon goes arthroscopically into the knee and creates small holes in the bone where the cartilage is missing (in my case the femur).  These holes allow the stem cell containing bone marrow to leak out of the bone and form a blood clot at the area of bone lacking the cartilage.  The stem cells then transform into another type of cell, a chondrocyte.  The chondrocytes are the cells in charge of cartilage.  The cells are embedded within the cartilage and secrete the collagen and proteoglycan proteins that make up the cartilage.  With microfracture we recruit and turn stem cells into chondrocytes that fill in the gap of cartilage.  Unfortunately, the chondrocytes recruited do not secrete the same mixture of collagen and proteoglycan proteins contained in that beautiful slick and strong articular cartilage.  Instead we get a different “type” of cartilage called firbogenetica cartilage.  But it works, for a while.  How long you might ask, and I certainly did? Well the data is not clear on that either.

So why did I choose microfracture if I knew it wasn’t going to make the right kind of cartilage (see a detailed review on the different techniques here).  Well there were a few reasons.  One is that it generally works and it works better for younger (<40), healthy, and normal weight individuals.  So I’m optimistic there. Second, it keeps all the other options on the table.  Other techniques involve taking a biopsy of cartilage from somewhere else and growing it up in the lab or putting it straight into the existing gap.  These techniques work well for larger gaps, but you can only do them once and the replacement cartilage doesn’t always stick.  Athletes have come back from microfracture before.  Several NBA and NFL players have returned to play following the procedure, but many don’t as well.   Most data actually shows no difference in outcomes with the various techniques in patient populations.  Studies do show that the inferior cartilage breaks down though and perhaps I will get 10 years out of my imposter articular cartilage.  Still all of this data is population based – I could be lucky and never have pain again, or in 4 years I might be under the knife again.  Large studies with lots of people don’t tell you exactly how your unique situations will respond.

My PhD mentor always told me that I could spend 26 years being active or focus on competitive 26.2 mile races, meaning I was to jeopardize my long-term health for a short term athletic goal?  However, I had running mentors who were older (and healthy) and that reasoning always felt like a false dichotomy and certain data does back that up. I certainly did not get here because of an over use injury but instead an underuse of my intellect.  But now the question does seem relevant.  When my doctor said that with this surgery I should be able to run again I was taken aback.  I had actually being riding my bike and coming to grasp with the idea of coaching rather than competing.  I was coming to grips with closing that door.  But now…I’m not so sure as like many of you and others it has become a part of my identity, my meaning, and my passion.  Not running has been a struggle, but then again 26 miles or 26 years.  As I move forward with rehab and I plan to share the process. That much is known even if the place that the process is leading me to is not.

Marcus Aurelius Quote. Definitely, can learn from the Stoics in this situation.

For more papers on various ways to deal with cartilage defects:

 

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Who am I?

[Brief background. While in Scotland on a trail run in May of 2015 I fell and hit my left knee HARD on a rock.  Ended up with a big cut and nothing else….so I thought.  Since then the pain in my knee has been creeping up in intensity to the point of causing me to limp in the mornings or stop in the middle of my runs.  Over the last two months I finally did something about, seeing the orthopedist, getting an MRI, and having a surgical consult.  This post is about the next step psychologically, not physiologically]

She stated firmly, “Nobody wants to read a blog post about an injury”.  Like most things I realized Bridget was right (thats why I’ll marry her).  So instead of writing about acquiring a potentially life changing injury, I’ll write about the prospect of losing a significant part of my life.  Thats inspiring, right?

The last couple months my Strava page is beginning to look like that of a technophobe.  As my kudos numbers atrophy away I wonder what other people think.  Are they thinking that I’m doing “secret training” (pre-Strava, called training).  I imagine once a week, on a group run people asking aloud, “What happened to Matt Laye”.  However, in reality its more like off of Strava out of mind and thats the crux of my problem.  Without running, who am I?

I secretly hope that my cartilage is superhuman and unlike those of others which are incapable of repairing themselves, but deep done I am starting to come to grasp with my own mortality in a purely running sense.  Bone on bone lack of cartilage does not repair itself, it breaks down until you need a repair.  At the moment all repairs are temporary despite some amazing treatments being developed. I imagine no number of second opinions will make me insured for experimental treatments reserved for multi-million dollar athletes and those who live moment to movement with excruciating pain.  So, I’m again faced with the question, without running, what do I do?

Now that I live in Boise I have a number of ways to reinvent myself.  Amazing mountain biking trails, skiing 15 miles from my front door, rock climbing 20 minutes away, and even a triathlon scene that is welcoming and down to earth.  But on a day like today when I get back from work tired and beat down its always a run that beats that beer in the fridge (at least initially).  For the last 20 plus years its on the trail and the road on my two feet which helps troubles, seasons, and time pass effortlessly.  Its comforting, its familiar, so its not just who am I or what will I do that I ask, but what will I become.

I’m fascinated by self-improvement.  Devouring books like “The Willpower Instinct”, “The Power of Habit”, and “Mindset”. I listen to podcasts about happiness, so called deconstructing world class performers, and improving my teaching constantly in my ears.  So I know a beginners mindset is a good thing.  Trying new things, stretching yourself, and even failing all make you stronger. But yet even thinking about letting go of running, of that massively important part of my ego, source of happiness, friendships and successes, is downright terrifying regardless of the benefits I fully know and truly believe await me.

Filling the void left by running is so much more than finding a competitive outlet.  As my high school coach Brian Davis said, “running is not a sport, its a lifestyle” and its been my lifestyle for so long.  Hence if I was a runner, who am I now, and more importantly who will I become.  I know that feeling a void left by running includes try to come to grasp with Matt Laye the non-runner and coming up with a better blog subtitle than “Adventures in non-running by a scientist”.  For now know that I’m not secret training offline.

[Post Update: August 27th, 2017. I recognize now that running is not what defines me, nor is the non-running options that I thought about so hard.  This entire time I was not asking the right question.  This idea of “I”, “self”, and ego are not the correct things to focus on.  As my meditation has deepened and my reading of stoic philosophy increased I am starting to understand that what I can’t control does not define me. The self is an illusion that we try to aspire to when all we have is our thoughts and physically being in this specific moment.  So I am not a runner, or a scientist, or a teacher, but I am me in this moment as much as I can be without as little ego as possible]

Hamstring Tendinopathy, a real pain in the…

Oh you thought you would win you silly hamstring injury, you thought you would go ahead stop me in the midst of my best training, racing, and most enjoyable block of running ever.  And you did for a good amount of time, but now I’ve figured you out and am ready to rid my life from you.

My hamstring issues had lurked in my mind and in my body for months until the Ice Age Trail 50 miler.  After Ice Age I recognized I had a problem, after Bay2Breakers that problem soon was serious.  So lets set the scene.  I’m having the best year of running.  A new half marathon PR, unbelievable 100 mile trail debut, and a 4 min marathon PR at Boston made it easy to ignore the hamstring.  I mean all that was required was a few easy miles to warm up and to stay away from running under 5 min pace.  Those problems seem trivial when training for marathons and beyond.  After Ice Age 50 mile there was no ignoring the pain though.  The pain was getting worse, not better, and even worse, I had Western States less than 2 months away.

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Head Case

Well, well, I can’t say I’m surprised.  I think this is the 4th blog I’ve started and almost the 4th that I quit.  But I’m not quitting, not yet. It’s not like I forgot to blog.  I thought about it a lot, but it’s hard to blog about running when you are not doing it.  I mean who wants to hear me whining about not running? Even my mom doesn’t want to read that*.

So let’s briefly summarize.  Coming off a marathon PR at Boston and a solid 50 miler at IAT I was preparing to run Western States. By the end of May I stopped running because of an upper hamstring injury….until about two weeks ago.  Okay that’s the simple story, and being injured is actually a lot more work than not being injured (I know this yet I still choose to neglect relatively easy preventative things).  I’ve actually been asked about my hamstring injury by several people and I know several more people that have had a similar infliction, so perhaps what I have to say could be useful…to someone…at sometime.  Hopefully it won’t be you.  I will write in a little more detail about what worked for me in my next post, but for now….

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Western States 2014 Race Report – DNS

Being injured always sucks.  Being injured right before a big race sucks even more.  Being injured right before a big race when a bunch of your friends are fit and ready to roll is the worst.  Right now I’m in the last position.  After finishing a 4 mile run this morning I think I have finally reached some form of enlightenment.  If your hamstring hurts and progresses to get worse after a 4 mile run you can’t run a 100 miles.  As much as I want to toe the line in Squaw and “gut” out a finish it just doesn’t seem to be in the cards.

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NBD: Injured with less than 30 days until Western

This was not how it was suppose to go.  I was suppose to recover from Ice Age and come back putting in my best training block of the year. I was supposed to be healthy & fit, toeing the line with the best 100 mile field in North America on June 28th in Squaw.  It was not suppose to be the time for my plantar fasciitis that I have been dealing with for more than 6 months to flair up, nor was it the ideal time for a manageable hamstring issue to move to a debilitating hamstring injury.  Yet that is where I find myself currently.

Stupidity is commonly defined as doing the same thing over and over expecting a different result.  The last few weeks I have been training stupidly; 2 days off, 1 run that hurts, 2 days off, another run that hurts.  I was expecting my body to heal itself without providing a novel stimulus to allow that to happen.  That’s not how physiology works, and I should know better.  After doing some self-diagnosing (always dangerous) combined with an some Active Release Therapy appointment (30 minutes and $185 later) I have an understanding of the problem.  It could be general tightness (manageable) or it could be an upper hamstring tendinopathy (6-12 weeks for recovery).

Regardless of the cause, the treatment is similar. There is a certain amount of relief in knowing what actions are necessary to remedy the problem.  It starts with diligent attention to my plantar issue, followed by eccentric strengthening of the hamstrings, combined with a bit of core work thrown in.  That is the action plan just to get healthy, but because I am not running I need to take an alternative approach to get fit.  Being injured is exhausting. Continue reading