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:

 

Advertisements

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]

More than a Fling

Loch Lomond and the entry to the Highlands

Loch Lomond and the entry to the Highlands

My “A” race is the wedding was my response to Dbo assertion that I either win or don’t bother coming back.  For me, often the race is secondary.  Its about the journey, the people, the landscape, and experiences surrounding the race more so than the performance itself.  My exposure into the culture surrounding trail running, outdoor adventures, and the Scottish highlands was well beyond the 7 hours and 4 minutes it took me to run from Milngavie to Tyndram, the first 53 miles of the well traveled West Highland Way.  It was dancing Ceilidh (pronounced “Kay-lay”) at the finish line, sharing beers with locals at the finish line, dinner in Glasgow with other trail runners, offers of accommodations during my travels, adventure advice, kayaking in Loch Lomond, and having my expectations for the beauty and wildness of the Highlands exceeded in every possible way.

Scottish traditional dancing is sort of like square dancing, but in a kilt.

Scottish traditional dancing is sort of like square dancing, but in a kilt.

I received the wedding invitation at a time when I was just starting to run again after my hamstring injury.  My hamstring was uncooperative, my disappointment from a DNS at Western sorely lingering, and my last race more than 6 months prior.  Still, when I travel I run.  Of course I was going to my friends Charlotte and Craig’s wedding in Scotland (especially since it was in a castle) and of course I immediately searched for races the weekend prior or after the celebrations.

Blair Castle - site of the wedding of Mr and Mrs Anderson.

Blair Castle – site of the wedding of Mr and Mrs Anderson.

Finding the HOKA Highland Fling one week prior to the wedding was just the first bit of the luck on my journey.  Soon I would learn that race director John Duncan was a coaching client of Ian Sharman.  I had my entry into not only the race, but also the local trail/ultra scene.  John graciously arranged my entire race weekend from pre-race hotel, finish line accommodations, and post-race hosts in nearby Glasgow with enough knowledge of the Scottish Highlands to create a lifetime of adventure itineraries.  I was excited about the race sure, but equally excited about the opportunities to interact with the local scene.

The West Highland Way, completed in 1980, is 96 miles in total and annually hosts more than 30,000 backpackers who walk the entire route.  The HOKA Highland Fling (Facebook page) covers the first 53 miles of it and contains a relatively tame ~5400 ft of climbing.  With the exception of a 4 mile stretch along Loch Lomond (the largest fresh water lake in the UK by surface area) the terrain is pretty runnable and lines up well with my strengths.  Still runners are treated to stunning views of the Highlands as various Munros and lower hills rise above the waters of Loch Lomond to the north.  In good weather it is stunningly beautiful, it bad weather it can be unbelievably miserable.

West Highland Way Route

West Highland Way Route

One problem with traveling for non running related reasons meant the inability to take much time to adjust to the 8 hour time zone difference between the West Coast and UK.  More accurately I had about 24 hours from when I landed to race time.  My strategy of going to bed earlier and waking up earlier (peaking at a 3:30 AM wake up) each day of the prior week clearly payed dividends as I had a full night of sleep and arrived on the raining starting line feeling relatively good.  My fitness was off from my ago, but I had managed several months of increasing training including a number of solid long runs and a strong 10 mile road effort to give me confidence to race rather than merely survive the 53 mile journey.

The rain that had saw us off the start line gave way to blue skies in the early miles in a prophetic manner that would parallel how my race would unfold for me.  Casey Morgan and Paul Navesey (of former 50k treadmill World Record fame), two strong UK based runners, took out the first quarter of the race quick and by mile 12 they had put 6 minutes into our chase pack of 3, a time I thought they would likely only extend all the way to the finish.  I spent those early miles in a group of 3 one of whom was Donnie Campbell who had just won the 130k Iznik Ultra Race in Turkey the week prior and was undoubtedly running on some tired legs. As I went to the front of our group up the only major climb of the day, Conic Hill, I was treated to increasing sunshine, my first views of Loch Lomond, and the southern Highlands “hills”.

The running from the bottom of Conic hill at Balmaha (19.8 miles) to Inversnaid (34.3 miles) was right in my wheelhouse; mostly flat, mostly wide, and insanely not technical.  I managed to establish a gap on Donnie and moved up into second when Casey had to unfortunately drop due to injury.  To my surprise the gap to Paul at first stayed at minutes (mile 27.2) and then decreased to 4 minutes by Inversnaid.  I briefly allowed myself to think, “huh, thats interesting”, but quickly turned my focus to how I was feeling and how to take care of myself.  15 miles out is still early to think about racing especially when stated time gaps are notoriously unreliable.  From Inversnaid you have a wonderfully technical, but not hilly section of trail along the lake which requires your full attention and any remaining athletic skill that road running and track hadn’t sucked out of your body years prior.  At several points I would look up in bemusement to how I got 10 feet below the trail and 3 miles later I was over rock hopping and grateful for the trail opening up to some more runnable trail as I reached the final checkpoint.

Hitting the final checkpoint, Bein Glas Farm (mile 40.9), I was starting to feel the effort and getting to the point of just wanting to be done.  Mile 40 was sticking my mind because of what Alex had said prior to Lake Sonoma 50, “after mile 40 everybody hurts” and hurting I was.  But apparently so was Paul as the time check was down to 2 minutes and within a mile of leaving Bein Glas I caught my first glimpse of Paul since I spotted him as a dot at the top of Conic Hill some 20 miles earlier.  As I ever so slowly caught Paul I realized that cruising in for second was not in the cards today.  It was race time and I was going to have to hurt.  I let that notion settle in over the a few miles as the gap ever so slowly closed, saving my energy for a big move rather than just catching him.  I didn’t want Paul fighting me for the final 7 miles to the finish line.  So when I eventually caught and passed him I tried to do so with ambition and did so for about 800m or until the route turned up a steep hill of unknown length.  Ugh, “You can walk when you are in the trees” I told myself.  For the first time all day I ran scared hoping to extend my lead and stay out of sight.  With 5k to go and an open field ahead I relaxed, it likely cost me the course record (by Sondre Amdahl), but it also ensured I did not blow up.  A mere two minutes after I finished Paul would come in to finish off a very strong effort of his own, one which actually saw him run a faster last 2.7 miles than me.

Before and after the race nearly every person I talked to about The Fling mentioned either how it was their favorite ultra race or it was the best ultra race in Scotland, if not the entire UK.  I don’t have that frame of reference, but I can say that on every level The Fling competes favorably with the best races in North America I’ve done.  Beautiful course, check. Amazing (and happy) volunteers, check.  Flawless organization, check.  Finish line fun, checkmate.  What happened after the race in many regards was more important for me than what happened during the race.  A large (heated) tent with beer, soup, music, massage, and of course a traditional Ceilidh dance.  I chatted with many a Scotman, Englishman, and occasional American.  All friendly and all having a great time.  I partook in their beverage buying generosity and patience to teach me a dance or two (that I put to good use at the wedding a week later to the surprise of many).  Knowing the history of the race its clear that race director John Duncan is largely responsible for this.  With infectious amounts of positive energy, time for everyone, and a constant smile on his face, its not hard to see why this race is more than a “fling” for the ultra community here and a great race to travel to.

Great trading card

Great trading card

Just waiting for the beer sponsorships to roll in...

Just waiting for the beer sponsorships to roll in…

 

Additional Links:

Strava Data

A great little video by Summit Fever Media about the 2015 edition of the race.

Race Recap by Scottish Athletics

Photo Album from my trip: Coming soon.

Why “Running Too Much May Be as Bad as Sitting Around” is BS

Its not a surprise that people are confused about the best medical practices to improve health.  Whether the recommendations are for diet or exercise it seems that every 3 months there is a contradicting advice from the medical community.  Eat eggs, don’t eat eggs, high carb diet, low carb diet (I still don’t know the right answer to that one).

Continue reading

My (Failed) High Fat Low Carb Diet Experiment

There I was in my general physician’s examination room trying to explain why I was eating copious amount of bacon, cheese, and avocado and wanting a more a more advanced cholesterol test to show that it wasn’t really doing me harm. It wasn’t going well to say the least. I think the word “moderation” make more appearances that standing ovations at a State of the Union address.   How did I get here I thought to myself? Continue reading

Sorry, Not Sorry – My 2014

After Boston I said if the season ended today I wouldn’t regret it. I should have knocked on wood or something, because my running was prophetically never same after that. After a lackluster performance at Ice Age 50, a greedy attempt to accumulate Montrail Ultra Cup points, I added stupid to injury by running the Bay to Breakers centipede with the West Valley Bros.  All I needed to do was to finish Western States and I would have won the Montrail Ultra Cup.  Instead Bay to Breakers was my last race of the year and I could hardly walk without pain while spectating Western. So in the end Ian, Mr. Professional, Mr. Consistent, walked away with that title to more than make up for my sneaky victory over him at Rocky  Maybe I should have continued to ask him coaching questions.

Continue reading

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.

Continue reading