14 days post-surgery

I am now 14 days post-surgery, and my quad is finally beginning to take on it's normal shape and size. And each day, I feel the strength returning to my leg.

Quarter-inch arthroscopy incisions laterally, above and below the kneecap. Still some swelling around the one below. Remnant markings of the patellar tendon and the word "YES" above the kneecap

Inch and three-quarter incision over the posteromedial tibial plateau. Definitely still some swelling but healing well.

First PT session

I had my first PT session with Jen this morning. I did electric stimulation of the quad, leg raises on my back and side, two quad strengthening exercises, and heel raises. I ended with ice.

Dates/milestones:
December 14th: Surgery
December 22nd: First post-op appt. with Medvecky; ditched the second crutch...mostly
December 27th: First PT session; swelling and numbness resolved...mostly
January 5th: Second PT session
February 9th: Second post-op appt. with Medvecky (green light to start strengthening the leg?!)

First post-op appointment

I had my first post-op appointment with Dr. Medvecky this morning. The place was a zoo, but I was brought right in and seen within minutes. Lucky me. Medvecky seemed pleased with the way things have progressed in only eight days; mostly that I didn't have much pain post-surgery, and that I had zero pain today. He removed the strips from the arthroscopy incisions and left those off, as they looked almost good and healed. He did, however, place some of those steristrips over the two-inch incision made over the posteromedial aspect of the knee to get to the semimembranosus tendon. Whatever. We discussed the numbness down the front of my lower leg and around my inner ankle. He said that the swelling--there is still some swelling--is probably putting pressure on a nerve and that the numbness will resolve once the swelling goes down. As a result, he'd like me to take ibuprofen. (But, I thought that you're not supposed to mix aspirin and ibuprofen?) He then did a cursory examination of the knee. I say cursory because it was done pretty quickly, but perhaps that's as thorough as he needed to be today. I have to see him back in 7 weeks.

Right after he said that I probably don't need physical therapy, he wrote me a prescription for 8 weeks of PT, 1 time per week. I can handle that. I've already made the appointment but not without hassle. I called up the clinic I've used in the past and told her that I had a script for PT. She responded that she was booking out past the new year. Fine. She put me down for January 9th and then asked about the injury. I responded that I just had surgery, and she said, "well, you didn't tell me that." Then she gave me an appointment for December 27th. Plus, I had to repeat my phone number about half a dozen times and clarify that my name isn't Brian, but Ryan. Clearly, I have little patience for this kind of stuff.

Anyway, Medvecky said that I can progress from two crutches to one, and then to full weight-bearing over the course of the next six weeks. I got a lesson on how to use one crutch. Never use it on the side of your bad peg!

7 days post-surgery

The first few days were difficult, trying to figure out what worked and what didn't, but I managed.

The nerve block wore off in my sleep the morning after surgery. Succumbing to the pain, I took a pain pill for the first time at 6/am. I took a total of four pain pills over the course of the day after surgery, and I have been off them ever since. Now, I have pain only when accidentally engaging my hamstring muscles, and for good reason.

My sleep has been interrupted due to some lower back pain from fully extending the knee; however, I slept without the knee immobilizer for the first time last night and, as a result, got considerably better sleep.

I achieved 90% flexion of the knee 2 or 3 days ahead of schedule. I'm able to bear some weight on the leg, but because of a sore shoulder from using only one crutch, I'm now using two crutches and bearing little weight on the leg.

My first post-surgery visit with the surgeon is tomorrow morning at 10:30/am. I will report more after that visit.

Chronology of Injury

MARCH 2010-FEBRUARY 2011
Consistently training for and running marathons; peak average weekly mileage: ~55

02/06/11: 2hr 24min run in Central Park; no pain
02/07/11: 47min run on treadmill; severe medial knee pain, almost causing me to abort the workout
02/08-02/19/11: Taper for the Austin Marathon; some mild to moderate medial knee pain (not only with running; e.g., even turning over in bed was painful)
02/20/11: Ran the Austin Marathon; no pain other than the usual general pain that you feel during a 3hr+ run

MARCH 2011
Tried to ramp back up after marathon, but pretty much shut down running completely by month-end due to pain

03/23/11: Saw Dr. Peter Jokl at Yale-New Haven Hospital; no imaging; diagnosed with hamstring tendinitis; treatment: reduce mileage and take anti-inflammatory (no improvement as a result of this treatment)

APRIL 2011
Tried barefoot running (some improvement)

04/06/11: Saw Dr. David Cohen at Connecticut Orthopedic Specialists for a second opinion; x-ray negative; diagnosed with hamstring tendinitis; same treatment as prescribed by Dr. Jokl (no improvement as a result of this treatment)
04/08/11: MRI
04/12/11: Follow-up with Dr. Cohen; MRI negative; same treatment (still no improvement as result of this treatment)

MAY 2011
Shut down running completely mid-month

05/20/11: Saw Dr. David Cohen again; treatment: rest; prescribed PT (no improvement as a result of rest or PT)
05/29-06/9/11: 5 PT sessions; stretching the hamstring muscles seemed to further exacerbate the injury

JUNE 2011
Still not running

06/13-07/9/11: 11 ART and SASTM sessions with Dr. Eugene Zeitler (some improvement as a result of these treatments)

JULY 2011
Resumed running mid-month

AUGUST 2011
Shut down running completely mid-month

08/10/11: Saw Dr. Matthew Boyer at Valley Sports Physicians & Orthopedic Medicine for a third opinion; diagnosed with medial joint-line tenderness (medial coronary ligament rupture and/or medial meniscus tear)
08/23/11: Follow-up with Dr. Boyer to discuss April MRI
08/31/11: Prolotherapy with Dr. Boyer; injected dextrose solution into knee joint, MCL and medial coronary ligaments

SEPTEMBER 2011
Some improvement after first round of prolotherapy

09/28/11: Prolotherapy with Dr. Boyer

OCTOBER 2011
Further improvement after second round of prolotherapy

10/21-11/04/11: 3 more chiropractic treatments with Dr. Zeitler (no improvement as a result of these treatments)
10/25/11: Prolotherapy with Dr. Boyer

NOVEMBER 2011
Improvement leveled off after third round of prolotherapy

11/14/11: Saw Dr. Michael Medvecky at Yale-New Haven Hospital for a fourth opinion; diagnosed with semimembranosus tendon avulsion; ordered MRI with arthrogram
11/22/11: MRI with arthrogram
11/28/11: Follow-up with Dr. Medvecky to discuss MRI; showed tendinopathy to 50% of semimembranosus tendon and inflammation in the bone at tendon insertion point; incidentally showed irregular medial plica; discussed surgery

DECEMBER 2012 (10th month of injury)
Surgery

12/05/11: Pre-surgery appointment with Dr. Medvecky
12/14/11: Surgery to debride semimembranosus tendon and excise medial plica

So, there you have it--ten months of nothing but injury and the resultant frustration. Every time I read through this, I'm reminded of the constant struggle and protracted effort to heal. It's further justification for the surgery that I had just five days ago. Unfortunately, rest and rehab for these kind of tendon injuries are a crapshoot, as evidenced above. But, so is surgery...I guess (we'll see). At the end of the day, regardless of the outcome, I believe that I made the right decision, and that surgery was the answer. I am going to do my best to get back to where I want to be as a runner, and I believe that, one day, I will be that runner again. I refuse to throw in the towel and give up. We're not talking about some inconsequential thing here; we're talking about something that drives me unlike anything else and makes me a better person. I know in my heart that I will always be the same person regardless of how my time is spent--running or otherwise--so one might question my assertion that running is of critical consequence to me. Here's the deal: I don't think that I would "go insane" if my body no longer permitted me to run (as runners typically say), but if that were to become the case, then I do think that I would miss out on a big part of what life has to offer us. I feel that the only way to achieve something extraordinary in my life is through running, as these kind of achievements are usually borne out of one's passion(s) (through my eyes--Jessica or my mother might say that I've already achieved something extraordinary in my life, many things in fact). I think that we all inherently yearn to achieve something extraordinary in life, because that's what motivates a life of activity rather than stagnancy, and I believe that's the very essence of life--moving forward and becoming the person that you ultimately want to be. So, it's no wonder that I take this bull by the horns. A lot, but not nearly everything, in my life rides on it.

A note that I made last month:
My gut is telling me that the injury to my right knee requires surgery. For 25 months, from December 2005 through 2007, I struggled with injury to my left foot. That injury ultimately required surgery, which corrected the problem. Now, nine months into injury to my right knee, I feel that it’s 2005 all over again. I’ve tried everything and am at my wit’s end with this injury.

Knee Surgery

I had knee surgery today at Yale-New Haven Hospital. Dr. Michael Medvecky performed the surgery.

After signing in, we took the elevator to the third floor and were brought to our room. The nurse went over some stuff, and then, to my surprise, told me that the surgeon had brought me in early for a nerve block. After discussing the nerve block with the nerve block team (yes, that's a right, a team--half a dozen doctors!), I was a bit hesitant about the procedure, as I didn't want another needle--in the groin, no less. After thinking about it, and at the recommendation of the surgeon, I decided to get it. It really wasn't that bad, granted they used a local anesthetic and I was sedated. Worse, actually, was the procedure to start an IV. The nurse first tried to start one in my hand, but my vein blew up, so she had to pull it out. Then she tried to start one further up my arm; that vein blew out, too. She gave up after two screw-ups and handed it off to a doctor, who was able to start it without a hitch. At this point, I was very upset, thinking that if they can't get this right, then what the eff are they gonna do to my knee/leg?

Once the IV was set and the block was performed, I was wheeled down the hall and into the operating room. There, they put a mask on my face, and the surgeon proceeded to shave my leg. The next thing I knew, I was in the recovery room. I scarfed down four packages of saltines with a cup of apple juice. When Jess joined me, she told me about the post-op meeting with the surgeon. She got pictures, too! The most interesting of the pictures is the before and after of the medial plica. With flexion of the knee, the pictures clearly show the plica contacting the femur (likely cause of pain). The after pictures show the removed plica, which kind of looks like a torn sponge. There are also a few pictures of the semimembranosus tendon. Unfortunately, the surgeon had to remove about 20% of the tendon that had turned a yellow color (dead tissue?). But, overall, the surgery went well, and I feel great! Now it's time to rest up and, in a few days, start my exercises.

Here's to hoping that this all heals up well, and that I'm back to running again in rather short order.

Tendon surgery

I was doing some research on tendon surgery today and came across this, which is a good description of the surgery I'll be having on the 14th:

"Surgery should include diagnostic arthroscopy to exclude any intra-articular pathology. If arthroscopy reveals no intra-articular derangement, then an incision is made directly over the direct head insertion of the semimebranosus tendon. The semimembranosus tendon is dissected free from surrounding tissue and the sheath is opened. Any areas of necrosis or degenerative tissue should be excised. Several longitudinal tenotomies are performed. In addition, the insertion site is drilled with a small Kirschner wire to promote a healing vascular response. Tendon rerouting or suturing the semimembranosus to the posterior aspect of the medial collateral ligament has also been proposed if friction between the tendon and the tibial plateau exists. In one report, the results of surgery were good in 9 of 10 patients, and allowed return to sporting activities at an average of 12 months postoperatively."

Source: Tendon injuries: basic science and clinical medicine, by Nicola Maffulli, et al.

December 14th

I am having surgery to remove the medial plica from my right knee (arthroscopically) and to repair the semimembranosus tendon (non-arthroscopically, as it's outside of the joint) on December 14th. The plica gets sucked out with a vacuum. The procedure for the tendon is a bit more complicated. In order to determine the extent of the injury to the tendon, the surgeon must pull the tendon away from the bone and then reattach it after he's done his business. Tendon injuries are usually to the inside of the tendon, so any injury is not immediately apparent until the tendon has been cut open. If there's damage to the tendon, then that part of the tendon must be removed. If it's just scar tissue, then it will be debrided. I hope it's the latter, obviously.

I can expect to be on crutches, partially weight-bearing, for 8 weeks. No splint, cast, etc. required. Only band-aids and a compression sleeve over the wounds. Showers are ok. This is all much easier than the recovery from my foot surgery. For that, I was on crutches for 12 weeks and couldn't get the wounds wet. Over 2 1/2 years later, I ran my second marathon. A long road, to say the least--hoping for an easier recovery this time around.

Surgery

I'll never forget it. It was February 7, 2011, and I was running on the treadmill at NHHR--a follow-up to a 17-mile long-run in Central Park the previous day--when I started experiencing severe pain on the inside of my right knee. I was tempted to stop, but I stubbornly pushed through the pain.

Fast forward 10 months, and I'm still dealing with the same pain. It has all but shut down my running. I've tried everything from RICE to prolotherapy, but nothing has worked. So, if all goes well with my appointments on December 5th, I'm going under the knife on December 14th. I'm not yet entirely sure what the surgeon has planned, but we'll discuss that on the 5th. All I know at this point is that there are two problems, one with the semimembranosus tendon, and one with the medial plica. Both light up quite well on the enhanced MRI.

What is most unbelievable about this injury--aside from the fact that it has sidelined me for 10 months--is that I pretty much predicted it would come to this back in February. I can remember thinking to myself on the treadmill that night that this is not good. But I just couldn't bring myself to abort the final few weeks of training and forgo running the Austin Marathon. The training went so well that I just couldn't do it, despite realizing that I was headed for trouble.

If the surgery works, which I believe it will, for I would not do it otherwise, I will have to make some major changes in my training. Those changes include, first and foremost, devising and sticking to a stretching routine. I am the world's most inflexible human being, and I believe that this has contributed to my injury. Secondly, cross-training and strength training are a must for me.

Another opinion

I saw Dr. Michael Medvecky at Yale today, because my ailing right knee seems to have stopped responding to prolotherapy. As previously reported, there had been some improvement, but I feel that it has leveled off, unfortunately. I was hoping to avoid surgery on the knee, but that seems unlikely now. The first two docs that I saw (orthopedists) told me that I have hamstring tendonitis. The third doc that I saw (osteopathist) told me that I have some stretching of my MCL and the medial coronary ligaments of the knee. The fourth doc, Medvecky, told me that I have a partial hamstring tendon avulsion--if I understood him correctly--which is the tearing away of the tendon from the bone. I'm scheduled to have a contrast MRI (big bucks) on Tuesday, Nov. 22nd, and I will follow-up with Medvecky on Monday, Nov. 28th. He said that if it is, in fact, an avulsion, he would need to surgically reattach the tendon to the bone and debride any scar tissue that has formed at the site of the injury. Fine. Do what you you gotta do.

Then, of course, there was the bit about how we can try to get you back to where you were, but there are no guarantees. I don't need a surgeon to not guarantee me anything, I just need him to repair the injury, and my body will do the rest. If there's a will, there's a way. I learned that with my foot. Before learning of the injury to my foot, I was told by a podiatrist that I would have to limit my running to 8 miles per week if I wanted to do any running at all, and then I went on to average upwards of 55 miles per week and run four marathons without even the slightest protest from my foot.

In the meantime, I'll be mostly biking with some occasional running thrown in there. Just because I'm not in excruciating pain doesn't mean there's not a serious problem. Literally, the day before my foot surgery, I ran 7 miles with very little discomfort. Eventually, things quiet down, and one begins to question whether there is, in fact, a serious problem, but once one begins to ramp up, the problem rears its ugly face once again. And that's what's happened with the knee.

Nov. 7-14

Monday, Nov. 7
Treadmill: 0.5mi; 6min (Adrenaline)
Was very tight today. Perhaps pushed it too hard yesterday. I'm not too concerned, though. Biked for 10 minutes, then tried to do 10 minutes on the treadmill, but my legs weren't having it. Did lunges and tried deadlifts. Some core but still sore.

Tuesday, Nov. 8
Wilbur Cross H.S. track: 1.5mi; 16min (Adrenaline)
Still tight. Some discomfort down the front of leg. Biked over. 6 laps around (2:40, 2:42, 2:42, 2:40, 2:40, 2:39).

Wednesday, Nov. 9
Treadmill: 0.6mi; 6min (Minimus Trail)
I think I need to deemphasize running for the time being because I'm really tight and sore. To that end, I got on my bike and rode the 16 miles to and from NHHR. It looks like I'm going to stick to the bike and strength stuff mostly for a while until I feel comfortable running. The problem is that I'm growing quite impatient and if I continue to run I know that I'm going to overdo it, if I haven't already. God, this is getting old.

Ran out of motivation to continue reporting here but have been doing a fair amount of biking. Going in for surgery on the 14th of December. 12/11/11

Oct. 31-Nov. 6

Monday, Oct. 31
Treadmill: 1.9mi; 20min (Adrenaline)
Didn't have as much discomfort in the front of knee but tight in back. Otherwise, felt good. Core afterward with JB. Worried about bite on back of left leg.

Tuesday, Nov. 1
Wooster Sq.: 2mi; 20min (Minimus Trail)
Chilly. Felt pretty good except for still worrying about rash on back of leg. Some strength afterward but back sore from yesterday's introduction of new core exercises.

Wednesday, Nov. 2
Treadmill: 1.9mi; 20min (Adrenaline)
With the exception of some slight fatigue in my legs, felt good. Oh, and a little tight. Core and stretched out.

Thursday, Nov. 3
East Rock: 36min (Minimus Trail)
Had planned on the stationary bike and a short run at the gym tonight but instead hit up East Rock with Dan. Ran to the summit and back down the same way. Dark forced us onto the park roads for the last little bit. Biked the roundtrip to the trailhead. Strength stuff at home afterward.

Friday, Nov. 4
Treadmill: 1mi; 10min (Adrenaline)
Biked for 10 minutes, then moved over to the treadmill. Felt fine. New core routine and lots of strength stuff. Stepping it up.

Saturday, Nov. 5
Treadmill: ~15min (Adrenaline)
Treadmill turned off so don't know exact distance and time. Biked for 15 minutes, then moved over to the treadmill. Felt good. Had to cut the visit short because Jess had to get to work. Sore from yesterday.

Sunday, Nov. 6
West Rock: 37min (Minimus Trail)
Lovely day with Jess and Dan at West Rock. Started at the lake and headed east; came back on white trail and then did a loop around lake. Not sure of distance because I stopped somewhere around the lake (felt fine, but didn't want to push it). Legs at gym afterward. Core still sore so passed on that.

2hr 38min running