The Graphic Details - Chapter 2 continued

So what really scared the crap out of me and really made the condition known were the photographs from inside my knee. Sure, having the doctor tell me what was wrong was pretty effective, but actually seeing the difference and conditions inside my knee really made an impression.
First, this is what a healthy knee is supposed to look like. This is the medial facet of the patella and the trochlea (knee cap and inside of the femur):



See how the surfaces are smooth, unfettered and there is no discoloration? Nice, huh?
Now let’s move to the lateral portion of my knee (the outside – where the illiotibial band connects into the knee joint.) This is the back side of the patella – called the lateral facet.











And so is this.




This is more towards the ridge (middle) on the backside of the patella. See how it’s right down to the bone – the white stuff is the hyaline cartilage and is supposed to have a continuous and smooth appearance and not look like it was just hit with napalm.

And now the kissing part of the lesion. This is the “base” of the femur where it meets the knee joint, called the trochlea.



The top of the image inside the circle is the trochlea and you can see how it’s not worn down to the bone, as is the patella on the bottom (bottom left inside the circle you can see the exposed bone). This is a Grade 3 lesion – blistered and damaged but not gone.

So these pictures pretty much stopped me in my tracks and has me second guessing pretty much everything I do. The unfortunate thing is that the conclusion is inevitable but the path I take to get there is what I’m trying to affect. More impact = a faster path to osteoarthritis. Hopefully the lower impact options will prove effective...both in knee longevity and weight management.

The really shitty part is that I’m really just not looking forward to spending a few thousand dollars on a new bike. Crap, that’s a lot of pairs of running shoes! I’m not going to buy used as I don’t really know anyone who is selling a bike and I have enough problems of my own. I don’t need to buy someone else’s problem(s).

I can't wait to get outside though.

Knee - No Progress, Chapter 2

(I have actually had this written for quite a while but never got around to posting it. So here it is, finally, with some recent modifications.)

I spent the 4 weeks between my (12/2) surgery and first post-operative meeting and my meeting in early January (1/10) researching options for treatment or repairing my knee. Whether it was reading what wikipedia had to offer, soliciting articles from various medical journals, digging into other online resources (www.cartilagecare.com), investigating advertisements seeking candidates for knee pain studies or contacting pharmaceutical companies for information on their latest technologies…I was on it.

Not that I wasted my time but unfortunately none of it is applicable to my situation. I guess any knowledge gained is good knowledge, but it sure as hell is frustrating.

After meeting with my doctor in January, in the middle of a 20” snowstorm nonetheless, it turns out that I have a kissing lesion, so it not only affects the patellar articular cartilage (Grade 4 defect), but my femoral condyte (lateral troclea) is also damaged to some extent (Grade 3 defect). That means that I have damage to the cartilage on the backside of my kneecap AND to the tip of my femur – the two surfaces touch when the knee is cycled, therefore it’s called a kissing lesion. And, to boot, neither lesion is contained...meaning, there is no definite edge to the outer edges of damaged cartilage. The edges of the damage is still frayed somewhat and it was left that way intentionally. Because the cartilage is in such limited supply, it’s better to be left in place even if it is damaged. Only the fragmented and floating pieces were removed as a conservative measure. (as part of the synovectomy – removal of the synovail sac in the knee (the sac full of fluid that increases the lubricity of the knee).

Makes sense, I guess.

My orthopedic surgeon is the top dog in the area and I trust him implicitly as he is a conservative physician, he really knows his shit and is an athlete himself. He spent a good portion of my January visit explaining his philosophy and talking me off of the cliff of taking any drastic actions while "my head was in it". He emphasized patience and that I can and will return to some activities if I want, but everything comes with a risk. This knee issue is going to be a process – a long process. Right now, we start with the most non-invasive and easy to implement options to see if we can work with what I still have and keep some level of activity to keep the knee strong and stable.

So what does this really mean?
Obviously anything I do is my own choice. I could start running anytime if I really wanted. I could also seek a second opinion or give the cartilage replacement technologies a try (like autologous condrocyte implantation). In the end, the pictures say it all and the conclusion is likely to be the same. Long distance running is out of the question…for now. He even frowned on 10K's (this little bit of advice or specificity is something that I actually had to pry out of him). So, again, I am not running now or anytime in the near future…but I haven’t ruled it out entirely. Stationary biking has at times been quite uncomfortable as has, believe it or not, swimming. Sure swimming is uncomfortable because I totally suck at it but some of the kicking motions at times tweak my knee. The indoor stationary exercise just hasn’t been cutting it for an equivalent caloric burn or from a motivational (or fun) perspective. I am heavier than I have been in about 8 years (*) and I don’t really look forward to any of my workouts…they’re just flat out boring!

(* - some of this is admittedly muscle. I have been lifting 1-4 times per week on average. There is an obvious and ever increasing layer of fluff though that’s pretty nasty.)

It’s time to go road bike shopping…or better put, bike buying.
I’ll include some pictures from my post-op report in a separate post. The pictures really tell the story.

Knee To This Point - Book 1 Of The Novel

The Recap:
Things seemed to be "normal" until October 15th...then my knee swelled up and didn't get better. By the following Wed, it was still swollen and had some general pain (a new symptom) so I called my ortho friend and was able to get an appointment that Friday, with an MRI.
I continued to run a little, logging a 6 miler the following day and put in 15 miles the following week (a light week) and 27 the next. Then, we had to shut it down.
Other than walking on the TM (at an incline) and stationary biking, i wasn't really alllowed to do much else.
I had the knee aspirated (drained) on 11/3 to have the fluid tested for gout, rheumatoid condidtions and Lyme disease - thankfully they all came back negative.
Next, it was time to schedule the diagnostic arthoscopy as no other causes of the swelling had been found (other than some suspected arthritis behind the kneecap).

So, 12/2 I was schedule for and had the diagnostic arthroscopy of the right knee. The procedurel was quick and the doc gave me the news after the procedure but the general made me feel like a drunken freshman. I couldn't remember a thing other than he said that he saw a lot of bone and did the synovectomy (removed the fluid lining in the knee). Physical therapy started the next day and I was still in a fog from the general and the codeine...and I drove myself to the appointment (doh!).

Physical therapy continued to progress and I had my post-op appointment with my doc on 12/15 and then the really bad news hit. The good news is that my knee is in really good condition - all ligaments, the meniscus and other connective tissues are excellent. Other good news was that the synovectomy seemed successful and he was able to remove much of the floating gunk in my knee that was causing some of the pain and swelling. The bad news was the condral defect on the back side of my kneecap, called a lesion of the patellar articular cartilage. Basically, this is a hole in my cartilage likely caused by some form of traumatic injury (like running into a chain link fence column full speed while catching in a baseball game) and instead of healing it progresses over time like a speed bump. Well, it must have reached (close to) critical mass for it to swell and be painful. Typically a condral defect is a direct line to osteoarthritis and because my defect was already abraded down to the bone, I am well on my way. The pictures of the defect (I'm trying to get copies so I can share) were pretty nasty - it looked like an explosion with jagged edges sticking straight up.
I was dumbfounded. Scared. Bummed. Confused. Aimless.
I still am.

So, since then I have been reading on condral defects and their remedy, speaking and exhanging information with Genzyme on their Carticel process and considering how I want to or should progress.

My thoughts moving forward....

1) No running for the foreseeable future. Since part of the diagnostic arthroscopy was to perform a debridement around the rough edges of the defect, I don't want to cause any further damage from pounding or excessive strain. Any further damage means more intrusion (operations) to make a clean site for implantation if I choose the options I am considering.

2) Pursue autologous condrocyte implantation (ACI) as the option for my knee. In speaking with my doc the last time I was there, he didn't sound too optimistic in general, but mostly for microfracturing the surrounding bone (a common, seemingly short-term, fix for chondral defects - it causes the marrow to leak into the defect forming fibrocartilage - sort of like a cartilage scab. This is a different structure and type of cartilage than the hyaline (hard, glossy cartilage) that exists in the joint. Over time, the fibrocartilage can loosens and break free - it's not as durable as the hyaline cartilage), mosaicplasty (age limited - typically patients under 40 size="3">or use of a synthetic patch (implanting a durable substance {sometimes a smooth metallic surface} in the chondral defect to protect the bone. This has a limited lifespan and will require that I restrict my activities for the rest of my life). So other options don't provide a very good outlook.

3) Since I have a patellar chondral defect, and not a "kissing" defect, my chances that this is likely to be covered by insurance are not as good. If I had a kissing defect, it would be more likely covered by insurance as ACI used for femoral defects is FDA approved.
(A "kissing defect refers to a defect on both sides of the condyle surfaces - the patellar and femoral condyle - luckily, I don't have this). I have an uphill battle with this one but during my coversation with Genzyme (the owner of the Carticel process) they seemed to be more confident as long as other invasive/uninvasive options have been pursued or would prove useless or are infeasible. I'm hoping that my doc will go on record that a temporary fix isn't worth it - it does nothing for my quality of life.

4) I'm curious if the insurance company will deem ACI a non-critical procedure - I can still bike and swim, I just can't run. This would be ruinous. Not only from a selfish perspective (running marathons, etc) but from a quality of life perspective in enjoying life with my family, etc and always having to worry that I am fast tracking to osteoarthritis and whatever I do could further accelerate that process.

So, in a nutshell, that's where I stand. I have an appointment on 1/12 with my ortho to discuss moving forward, his thoughts and hesitations on my prognosis and potential for fixing my knee. I have no plans on toeing the line any time soon so you'll all have to pound out the miles for me. I'm jealous, that's for sure as I wish I were out there enjoying the cold air up my nose and in my face. In the mean time, I have to keep my BMI down so I'm still elligible for the surgery.
Seriously.

Yikes!

...more to come. sorry it has been so long.

The 2010 Cycle

The Training:
Coming off of a real test of my will to finish a marathon at OBX (November) I was looking forward to putting a solid winter training cycle together for a good bout with the Boston course. However, just after coming home from a pre-holiday work travel trip my back locked up in an unforgiving spasm leading to 3+ weeks of no activity other than physical therapy and back strengthening exercises. In addition to three zero-mile weeks, I had to rebuild my mileage which took a little longer than I expected and I was forced to sacrifice both speed workouts and race events. January turned out to be a 71 mile month or about ½ of what I normally try and bank for the month. Not a good way to start off the program, for sure. One last factor was the post-holiday fluff that I was sporting. I had managed to crawl back into the ranks of the true Clydesdales – a value on the scale I hadn’t seen in 2+ years. That was pretty depressing.
February turned out to be a better mileage month (120) although it was still only ¾ of what I had run in previous marathon cycles. Still building base and focusing on hill workouts to build my strength, I was also doing some weight lifting to build upper body strength – the running induced muscle atrophy in my shoulders gave me the feeling that my shoulders were floating in their sockets. I was mixing one or two days of core work in but still feeling like my back could give out at any time so my confidence and desire to pound out the miles were both suffering. Then my knee swelled up to twice its normal size – an obvious sign of ramping up my miles a little too quickly while carrying around a bit too much weight. I actually think the blown up knee was caused by some of the cross training lifting I was doing, specifically hamstring curls on the exercise ball. Okay, no more hamstring curls but still I lost some valuable training days and miles to yet another annoyance. My long runs were making their way into the 16-mile range but instead of ramping up, staying at a base distance to let my body acclimate, I had to press forward, increasing both the weekly base runs and my weekend long runs.
Despite being a little dinged up, March turned out to be the second thickest mileage month (192) I had ever put together. Necessity does wondrous things I guess. I was finally able to start folding in some longer distance tempo and progression runs (8-10 miles) an 18-miler and two 20+ mile runs but I still wasn’t able to drop the extra poundage as in the previous two years. This was worrisome, but at this point I wasn’t shooting for a PR come April 19 – a solid effort in the 3:30’s and avoiding a major late mile blow-up was my target. I was also planning on a two week taper as opposed to three weeks.
April started with my last 20-miler and then I jumped into taper. Taper was okay, I didn’t go out of my mind and my resolve was pretty solid with respect to my self-induced zero booze, junk, and dessert mode. My cheats were one glass of wine, about 20 M&M’s and a few potato chips here and there. I didn’t have the chance to weigh myself before and after but I didn’t feel like I had softened up with unnecessary weight. In fact, I think I lost more weight in taper than I had during training. I got a little boost when I got a note from a fraternity brother (who I hadn’t seen in quite a long time) that he was looking to run about the same pace/time and would be in the nose-bleed corrals as well. Very cool…a running partner for Boston. Something I hadn’t had in quite a few years. It was his first Boston so he accepted the offer to come down to the house (Respite) pre-race and enjoy the peace and solitude. In addition, some other out-of-town friends were coming down (some of whom were also first-timers) so I was looking forward to seeing everyone.

Race Day: Great weather…check.
Pre-race pancakes…check.
Pre-race purges…check.
To kill time in the corral, I made my way around and was wishing all other Respite runners well. After the 2nd wave start sounded, I ended up having to wait for 3 corrals to pass before connecting with Alan so that meant an additional 3,000 runners that would be on course in-front of me. Great. We walked up to within 15 feet of the starting line and off we went. I actually started my watch early…by about 3 seconds. Time in the bank for me. Heh.
To say the course was crowded is an understatement. It didn’t seem any worse than previous years but still the amount of energy I am having to burn to get some form of pace started up, find space to run and avoid the slower milers is just ridiculous. I don’t feel taxed, never lost my breath and Alan and I are able to stay within line sight of each other. There was no chance at running tangents or even staying on one side of the course. We were constantly switching sides trying to find the open road. I started drinking at mile 3 and was happy to see the 5K mark pass. After an expected slow mile 1 we inadvertently dropped the pace into the low/mid 7:40’s and tried to find our way back to the 7:50 – 8 mpm range. Funny thing, we never really discussed a goal pace and I think we both just let comfort take control of our race. There were times that the crowd barriers necked down causing some pretty bad bottlenecking and really limited the space to run (Framingham @ the 10K especially). We were able to find some room after Framingham and start to run some tangents but we were still dodging a lot of runners and wasting precious energy. Coming into mile 10 a female runner decided to break left for the port-a-johns and pulled a rear leg sweep on me. I nearly Supermanned into the pavement only to catch myself before touching down with my hands. WTF?!? I’m just lucky I didn’t pull or pop anything.
I got a pretty good boost from the Respite Center crowd at mile 10 (and a Powerbar). Alan and I stayed together for the next several miles and I was giving him some cues on what was coming, we checked each other’s pace and told a story here and there. We made it up the Rt 128 (mile 16) hill with a pretty even pace and entering the 2nd hill I told him I was going to back off a bit. I lost sight of him around mile 18. It was here that I had my first communication with my right quad – a slight quiver waiting to cramp. I focused on cutting all tangents, took my Gu and tried for force fluids down (I wasn’t feeling much like drinking). I passed an acquaintance at mile 20 and wished him well. My hamstrings were now starting to talk so I had to constantly switch my stride, short to long and vice-a-versa to keep from cramping. I was able to hold off the cramps until mile 24 which I was pretty happy about. I did run through a lot (cramps & pain) more this year than in races past so if anything my experience was helping to manage the muscle fatigue. I was forced to take my first walk break on the uphill for the Mass Pike bridge – I knew I’d lock up on the uphill if I tried to power through it and I figured I’d save some for the last mile +. I took a few more very short walk breaks to fend off leg cramps that would have been completely stymieing. The last walk break I was intending was at the top of Hereford Street, the final turn, and I was trying to lube up my legs enough to make the jogging motion for the last 3/10ths of a mile.
I was able to hold it together for all but the last 30 feet. I was almost passed the VIP stands and in the paint for the finish area and my legs totally locked up forcing me to stop or fall over. I chose to stop – not wanting to make the 6 o’clock news. After a quick hamstring stretch I put together the last few rigid steps of my marathon and no sooner did I cross the timing pads and finish line, I locked up once again and froze in place. A volunteer was trying to get me to move but any movement felt like dozens of daggers being sunk and twisted in my quads and hamstrings. I pleaded for a few seconds to bend and stretch before I moved to the side adjacent to the finishing stands. Finished. I was finished and I felt finished.

I knew the last few miles were going to be especially difficult given my abbreviated training cycle but standing there rigid in pain, I just wasn’t feeling satisfied or like I had accomplished anything. I chuckled to myself that I almost ran the perfect race for my training but I was 30 feet shy. I started to make my way down Boylston to get my foil blanket and vittles and Tracy was waiting for me on the barrier fence. We chatted for a while, said hello to another Respite runner (qualified), took a few pictures and parted ways to meet up at the post-race meet-up.

Seeing everyone after the race was great and finally having my better half meet some of my virtual friends was nice. Now I can put a few faces with names and it won’t seem as foreign to her.

Fighting the crowds in the back of the pack is getting old…really old. I know I burn way too much energy and attention having to weave and bob, changing pace and moving from side to side on the road. I have been saying that it’s good inspiration to try and qualify but after enduring such a cataclysmic collapse at the end of the OBX marathon I don’t care to relive that pain anytime soon. I have to evaluate where I want to go and what I want to do over the next few weeks, while starting my short cycle to get ready for Mt Washington. I’m debating on early registering for a fall race, buying a coach (garmin) and seeking some advice on training tips to put forth an effort to give a 3:20:59 a shot. I don’t think I was very far off last year but as with anything, the last 10% will take 90% of the effort. Shaving an additional 10 minutes off of my PR will be a stiff task.

Splits:
8:35/7:42/7:48/7:49/8:02/7:51/16:10/8:00/7:55/7:55/7:47/7:51/
7:50/8:00/7:59/16:18/8:03/8:26/8:55/8:15/8:22/8:29/10:01/10:31/2:29

looooong break

So it has been a while since I've been here. Welcome back, me.

Hope you're all doing well. I'll try to come back soon and catch up on the past 5 months.

peaks, valleys and plans - posted September 16

So my tempo run 2 weeks kicked some butt. I felt good and was really trying to keep my level of effort (breathing/turnover) hard and yet still smooth. It panned out. I don't run w/GPS so I don't have a clue what pace I'm running at any given point. Management of my run is all by feel and paying attention to my effort level. I really try to pay attention to my breathing and turnover and keep them relatively the same for the run - factoring in hills and getting tired towards the end of the run which obviously will decrease turnover and increase breathing. The course I usually run my tempo (at work) is a long gradual uphill, followed by ~3/4 mile slight downhill and then more rolling hills that are mostly up (so they seem). It's not 'ideal' for a tempo workout but good for varying my effort and trying to keep a consistent pace.
The workout:
warm-up 1.6m 8:16mpm
tempo 1.8m 6:42mpm
tempo 0.8 6:43mpm
tempo 2.1m 7:05mpm
cool down 1.7m 8:52mpm
7.94m total (7:36 mpm avg pace)
Nice! I did peter out at the end of the tempo but really felt okay about my effort. The tempo pace is faster than I have done before - by about 20 seconds.
Note to self: that does not translate to a marathon pace of 20 seconds faster!

----------------------

So while I was out on my long run this past Saturday I again caught myself thinking that I could lop off another 9:21 from my marathon PR. This would put me at 3:20:59 and thus a BQ. My mind was really spinning as I struggled along.
I eventually came to the conclusion that I'm fu#king high if I think that's possible. That's a 7:40 pace - for the whole race! After struggling through the 22 miles, I looked back at my splits from Boston 2009 and I only ran 3 miles at a sub-7:40 mpm (see below). Also, if my past marathon performances have been any indicator, I'd have to bank 5-6 minutes (at least) to account for the late race fade.
(I have noticed that faster marathon times help me avoid late race cramping. I guess I can call that incentive to run faster.)

This may be a bit of a surprise, but I never really set a specific target pace or put a race plan together (scheduled splits) for any of my previous 9 marathons. Granted I had an idea of what time I wanted to run, but never really set a 'goal' per say. I actually mentioned this to a friend just before Boston and he said he could never run a race without a plan. I don't know if I could follow a plan to any level of precision just because there are so many unknowns that can and do occur in the course of a marathon. I have always had an idea of what I wanted to run but I typically ran at a level that I felt comfortable at and tried to hold it for as long as possible. Running to a specific plan seems like a situation ripe for disappointment. The scenario plays out sort like this...
- a goal pace is missed for a mile
- okay, make it up in the next mile
- miss the new goal time and have to make up even more
- repeat
- get tired and fall apart from mental exhaustion

(This doesn't really hold true to my 5K PR - I latched onto 3 guys who were running a 6:30 pace and held onto them until about the 2.9 mile mark. I ran a PR but not the sub-20 I was hoping for. Die another day I guess).

Now I'm pondering the thought of 1) a BQ and 2) running to a plan in a marathon? Not to mention, this will be on a course that I'm completely unfamiliar with (a few bumpy hills, portions that are dirt/wood chip paths and the potential for heat being that it's in NC)?
I just can't figure out if I'm serious about giving it a legitimate shot. I think it's too much pressure to put on myself and might detract from the level of satisfaction I get from running (I dare not call it enjoyment.) There's still just under 2 months to convince myself to try and go for it...or not.
I know what the eventual plan will sound like - run like hell, see if the 7:40ish pace is manageable and try and hold on. Let's see if we can execute it.


Boston '09 splits and the time I'd have to carve to BQ
Mile 1: 8:14 (-34)
Mile 2: 7:46 (-6)
Mile 3: 7:46 (-6)
Mile 4: 7:45 (-6)
Mile 5 : 7:51 (-11)
Mile 6: 7:48 (-8)
Mile 7: 7:49 (-9)
Mile 8: 7:47 (-7)
Mile 9: 7:46 (-6)
Mile 10: 7:36 (stet)
Mile 11: 7:39 (stet)
Mile 12: 7:44 (-4)
Mile 13: 7:48 (-8)
Mile 14: 7:48 (-8)
Mile 15: 7:27 (stet)
Mile 16: 7:44 (-4)
Mile 17: 8:09 (-29)
Mile 18: 8:09 (-29)
Mile 19: 8:08 (-28)
Mile 20: 8:12 (-32)
Mile 21: 8:47 (-1:07!)
Mile 22: 8:05 (-25)
Mile 23: 8:39 (-59)
Mile 24: 8:57 (-1:17!)
Mile 25: 8:41 (-1:01!)
Mile 26.2: 8:43 avg (-12 or limp home)

just catching up

Okay, I have to get back into it - this blog thing and running in general. Work, life, etc has been pretty demanding lately so my mileage has been way down - much to my marathon "training" detriment. So with 10 weeks left until OBX, I have to start cram-training.....again. My mileage totals for the past few weeks:

Week Ending - mileage total - long run
7/5 - 18.9 - 8
7/12 - 28.5 - 10
7/19 - 26.7 - 12.5
7/26 - 26.8 - 12
8/2 - 35.5 - 14.3
8/9 - 21.8 - 10
8/16 - 41.1 - 16.6
8/23 - 18.4 - 6+ (no LR)

My mileage was way down last week b/c of vacation and all of the driving we did. I did get 2 speed workouts so maybe that makes up for some of the slacking. Tuesday's workout was 4X800 +/-. I ran at a good clip for ~3:30 figuring it would be about 800m - only problem was I forgot which street I started and finished at after my turnaround (I ran an out & back). So, I wasn't really running for consistent pacing but more just to get some speed done.

I'm hoping for some solid weeks in the high 30s and 40s over the next few weeks. We'll see how that all pans out. No matter how hard I try, I just can't get my weekly mileage up there. I'm hoping that the 41-mile week wasn't an apparition.

I did have a nice hill workout today at work (2 mile run to get there & then back). Five repeats with splits of 1:19, 1:20, 1:21, 1:22 and 1:24. By far the speediest I have run the hill despite the extra baggage I'm carrying. I guess it provided a little shot of confidence - a badly needed shot of confidence. With all of the hot weather running lately, it's so hard to gauge my fitness level. I'm still feeling lost and everything feels slow and sloggy - even the speed workouts (today included). I'm waiting for that first light-on-my-feet run to happen. Not to mention, my running plan is so redundant. I try to mix it up with hills, intervals, tempo runs but I think I need a little more excitement in it.

Sorry for not being around lately and not checking in on you all. Work has been super demanding and there have been rumors that the IT police are at their old games again of public hangings.
Screw 'em.
Lots of travel lately as well.

Time to start cross training - this one dimensional thing will kill me. I have to force myself away from my desk on Thursdays for a swim/bike/lift session.

Got a bunch of personal stuff going on - dad getting 1/2 of his thyroid removed this week, uncle w/shoulder reconstruction, co-worker's wife has stage 2 breast cancer (I just found out today) and is in for several weeks of chemo, then surgery, then radiation...
Yikes. Life is starting to hit.

Good runs all.
Ciao

Oh, and I think a BQ attempt is out of the question for me. Just not enough time to get myself adequately prepared to give it a legitmate shot.