Resilience

Throughout high school and college, I always prided myself on being one of those runners who never got really injured. Sure, I had my struggles with shin splints and plantar fasciitis, soreness in my left bunion, and the occasional scrape or cut from falling on a trail, but never anything major. I could run to my heart’s content without ever having to take a time-out or visit a doctor. I just knew I’d be one of the silver-haired runners with smile lines and wrinkles around the eyes (mine would be soft ones, though, because I do actually remember to wear sunscreen from time to time) I often admired during races- a tough old bird running in a cotton T-shirt and gliding across the pavement, my years of running experience evident in my swift stride and lack of gadgets because when I started running back in 1987, those things just didn’t exist.

I first felt the pain in my left knee during an evening run in late December 2005. I remember the exact moment, rounding the last curve of the Mount Vernon Trail in Arlington, Virginia, on the gradual uphill that turns into the Custis Trail and runs parallel to Route 29 just after you pass the Key Bridge. I don’t recall tripping or altering my stride when I suddenly felt an intense pain under my left kneecap. I shook it off and finished my run, chalking it up to the bikram yoga class I had taken the day before, during which I strained my entire body trying to contort it in ways it just didn’t want to. I assumed the pain was temporary and continued my training cycle that winter in preparation for the Austin Marathon. I ran through the pain when I felt it, iced my knee afterwards, and swore I’d go see a doctor after the marathon.

In the spring of 2006, I saw an orthopedic surgeon – a friend of a friend of a friend… something like that. He was very kind, ran about a thousand tests, and didn’t charge me for any of them. Bone scan this and X-ray that, everything was normal.  Finally, he came up with a diagnosis: Patellofemoral Pain Syndrome. In layman’s terms: Runner’s Knee. Or, if you’re the inactive sort, Moviegoer’s Knee (yes, it really does exist, and yes, it really is the same thing as Runner’s Knee). You run too much, he said. Stop running, you’ll feel better.

Like every Type-A runner I know, the first thing I did upon learning my diagnosis was research. I learned that Patellofemoral Pain Syndrome (PFPS) is actually a very common injury. It’s an overuse injury, typically caused (ironically, assuming one is indeed a runner) by weak quadricep muscles that prevent the patella, or kneecap, from tracking properly when the knee is bent and straightened. When the patella doesn’t track properly, all hell breaks loose (speaking in medical terms, of course) and the cartilage begins to fray, causing some of the worst pain I have ever experienced. Women, thanks to wider hips, are generally more predisposed to PFPS owing to a greater Q-angle, which is the angle formed by the femur and the patella.

Shockingly, Stop running, you’ll feel better was not quite the response I had hoped for, so I made an appointment with a different orthopedic surgeon who specialized in sports injuries. She was more optimistic than the first doctor and told me that with the right combination of rest and physical therapy to strengthen my quadricep muscles, I’d be back in my running shoes before long. I followed her instructions with exercises at home and twice-weekly physical therapy appointments. In the meantime, following the theft of my bike, a hybrid that I used to ride to work from time to time, I decided to buy a road bike. I had always been curious about triathlons, and this seemed like a good time to start swimming and cycling and give my knee a chance to heal.

Following several weeks of physical therapy, rest, swimming, cycling, pool running, and even a few acupuncture appointments, my knee started to feel better. Or so I told myself. Sure, I’m fine. I’m doing all the right things.

I did my first triathlon in July of 2006, which actually became a duathlon (run-bike-run) owing to a rough storm that had rendered the Chesapeake Bay too polluted for swimming. I had already signed up for a half-Iron distance triathlon, however, so when it came time for that in September of the same year, I was terrified, having never actually done a triathlon before. But, I made it through, and my knee held up. I dropped out of the Columbus Marathon a couple weeks later but finished the Marine Corps Marathon a couple weeks after that. I ended my race year with a crummy marathon time and a sore knee…again.

As hard as it was, I took the next six months completely off from running. I did a lot of pool running, swimming, and some cycling during this time. In April 2007, I started running again, and I felt better. I began training, completed another triathlon and a couple more marathons, but none of them were great. My knee just didn’t feel right. It hurt sometimes, then felt better, then ached… the nagging nature of it took the joy out of running.

The day after the Marine Corps Marathon 2007, which I dropped out of at mile 19 due to knee pain, I called my primary care doctor and begged for an MRI. In all of my previous visits to other surgeons, no one had thought an MRI was necessary. When I finally got one, the results showed quite a lot of cartilage damage and a patella that was being pulled to the lateral side of my leg. My doctor wrote me a referral to see yet a different orthopedic surgeon. I was skeptical, but I made an appointment. The surgeon understood my pain as well as my desire to run. He said he could perform a simple athroscopy to release the patellar tendon that was pulling my kneecap to the lateral side and clean up the ragged cartilage. He also told me that a more invasive procedure might be necessary, depending on what he found once he had the camera and arthroscope in my knee.

I mulled over my various options, talked about them with my family, and weighed the pros and cons. Surgery was never something I had considered before – after all, I was one of those runners who never got injured! On one hand, my days of long runs would be over; on the other, my days of long runs and short runs would be over. I called the doctor and scheduled the operation for December 10, 2007 at The George Washington University Hospital in Washington, DC.

It was an outpatient procedure, but I was not prepared for what I saw when I woke up from surgery. My leg was in a straight-legged soft cast from the middle of my thigh to my ankle. I was still numb, so I couldn’t feel any pain, but the surgeon told me that he had discovered that my kneecap had been pulled so far laterally that releasing the tendon wasn’t enough; he’d had to completely sever the patella, manually realign it, and then reattach it with two titanium screws inserted into my tibia. I’d be in the cast for a month, he said, but I should schedule my first physical therapy for about a week to ten days from the surgery date. I was to keep my leg as still as possible. Shortly before I left the hospital, a nurse inserted a catheter into my left groin. It was attached to a plastic ball containing a liquid pain killer that would slowly drip into my leg over the course of the next 72 hours. The ball o’ drugs, I called it.

The next week was miserable. I had never experienced such pain before. After the ball o’ drugs emptied itself, I felt a constant throbbing pain in my leg that felt like someone was taking a hammer to it, over and over. The oral pain killers only made me nauseous; I could either be sick or be in pain. I chose pain.

I thought the situation could only go up from there. I was wrong. I went to my first physical therapy appointment, already stressed about how painful it would be to bend my knee. I had kept it straight in the cast since the operation, and I was terrified to bend it, because I knew it would hurt. Never did it cross my mind that I wouldn’t be able to bend it at all.

Drew, my physical therapist, however, did not seem at all surprised at this revelation. He measured my range of motion that day at 25 degrees. It was a number that meant nothing to me, so I asked him to explain it.  He said that in general, we use 90 degrees range of motion to walk normally, about 110 to cycle, and 130 or more to run, depending on how fast. I got a long way to go, I thought. He told me not to worry. If we were diligent, I’d be back to myself in no time.

I saw Drew, as well as Melissa, another therapist, religiously three times a week for the next three months and did my exercises at home. When my cast came off, I could touch my thumbs and middle fingers to one another as I wrapped my hands around my left thigh. It had atrophied to nearly half of its previous size. Drew brought me to tears more than a few times, bending my knee and stretching the range of motion. Every week, he measured the flexion. By the end of March, I had achieved only 82 degrees. I was frustrated and depressed. I hadn’t made any progress at all in the previous three weeks. Drew suggested that the culprit might be excess scar tissue that had built up after the surgery and was preventing me from gaining more flexion. The surgeon agreed that this was a possibility, but the only way to know would be to open up the wound and look at it again. I wasn’t crazy about this idea, but the alternative wasn’t so great either. And so, on April 4, 2008, I was back in the operating room. The surgeon performed a manipulation (bent my knee for me under anesthesia), redid the lateral release, and scraped away the excess scar tissue.

During the April procedure, the surgeon said he achieved 140 degrees’ flexion in my knee during the manipulation, so it was certainly possible to get full or close to full range of motion back. But, we’d have to be aggressive, he said. Little did I know that aggressive meant not only continuing the thrice-weekly physical therapy appointments with Drew and Melissa; I had to wear a splint on my leg three times a day for an up to an hour each time. It sounds innocuous, but the thing was downright medieval. See for yourself:

JAS knee splint. Photo: http://www.jointactivesystems.com

I wore it while sitting on the edge of a chair, with my knee bent. It attached to my thigh and my shin, and it had a crank on it, which when turned, forced my knee to bend. As I turned the crank, it put an unbelievable amount of pressure on my shin, to the point of bruising, and I could feel the ache in my knee. Within a week’s time, I had achieved 90 degrees; within a month, I was riding the stationary bike. I carted that contraption to work every day and used it at my desk. It was hell, but it worked. However, as my range of motion increased, there was one thing that still bugged me. My knee still hurt. As far as I could tell, it was the same nagging pain under my kneecap… I felt no differently than I had before the operation. My therapists and surgeon said it would just take time – months, maybe even a year – but eventually, the pain would go away.

By June of that year, my then-husband, who had been incredibly supportive throughout all of this, had gotten a job offer in Minneapolis, and we were making our plans to move. About a month before we left, I had asked Melissa if she thought I’d be able to walk/run a local 8K race. I had been trying to stay fit by swimming and walking gently. The race was scheduled for the night before we were planning to leave for Minnesota. The pain in my knee was still there, but it had much improved. Melissa said it was certainly possible, and that if I wanted to do it, she’d do it with me.

During my last appointment with my surgeon before my move, he took an X-ray of my knee. The titanium screws looked good, he said, and the operation had healed nicely. I had achieved 138 degrees’ range of motion by this point. I asked him if he thought I’d be able to run like I did before. He told me it was unlikely that I’d be able to run more than about five miles at a time, and that I probably wouldn’t be able to bike up hills. I’d likely never get the range of motion I had before, and I’d probably have difficulty squatting and kneeling for the rest of my life.

On July 21, 2008, I ran/walked that 8K with Melissa. It took me over an hour and I know I was limping the whole time, not because it hurt but because and my legs were still so disproportionate. We moved to Minnesota the next day and life began there. I started running again that fall, very gradually and gingerly, not wanting to undo the last nine months’ worth of work.

It took me over a year to recover from the surgery to the point that I could run without pain. As my leg got stronger, I ran farther, keeping my surgeon’s words in the back of my mind: …won’t really be able to run more than about five miles at a time…won’t be able to bike up hills…

Today I celebrate five years since my operation. The surgeon was right about some things: I still have a lot of trouble squatting, and I can’t really kneel. I can’t touch my heel to my bum, and I hate the feeling on my shin at the scar site when I touch it. Rugged terrain is hard to run on and I have to be careful when running uphill. I still experience pain in my knee from time to time, especially on cold, damp days, and I have to remind myself to rest when I need to.

However, the surgeon was also wrong about some things. I can run more than five miles, and I can  bike up hills… but most importantly, I can do those things comfortably and without pain. In fact, in the last five years, I have run more and better than ever before. To be exact, since December 10, 2007, I have completed seven half marathons (including my personal best of 1:45:19); three marathons (including my best of 3:42:29); an Ironman triathlon (2.4 mile swim, 112 mile (hilly!) bike ride, 26.2 mile run); and two 12-hour ultramarathons during each of which I covered approximately fifty miles.

The moral of the story: Never underestimate the resilience and strength of the human body and spirit.

Thank you for reading!

6 thoughts on “Resilience

  1. Thank you, Nicole! You are too sweet. Yes, I did IM Wisconsin in 2009 to celebrate my 30th birthday. I was one of the last finishers, at 16 hours, 32 minutes, but I didn't care. Easily in the top three best days of my life!

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