View looking at the inside of the right knee; front (anterior) of the knee is to the left. My injury is actually to my left knee.

But I have to do it.  What a difference a day makes.  Yesterday I was riding high on great news from a few different sources and today, I’m sitting at home, icing my knee and depressed about the fact that the knee is acting up again.

I say “knee” as a general term but the specific area that’s currently causing me problems is what the doctors call the “hamstring insertion,” the tendon that attaches the bottom of one of my hamstring muscles to my tibia (one of the leg bones below the knee).  The physical therapists out there are probably laughing at my description here but I’m going to try to keep it in layman’s terms.

Tomorrow is another big milestone day.  I have an appointment in the morning with Dr. Luke, my rock star orthopedist at UCSF.  Dr. Luke has treated Olympians and scores of professional athletes, so I’m fortunate to be seeing him.  I’ll have a post-appointment update soon!

Image by eOrthopod.

This is the fifth article in a series describing my first ever running injury in 20 years, how I’ve dealt with it heretofore, and my path to recovery.

Let me start out by saying the past two days have been days of good news.  My knee is feeling as good as it has in a while, I received some positive news on the personal finance front and a great friend landed a great job yesterday, all of which make me very happy.

I’m also due for the next installment of my injury tale so without further ado, here is where the story gets interesting.

I returned home from Germany on the most miserable plane ride I have had and firmly believe I probably will ever have.  Having no immunity to any German cold viruses, naturally I caught one.  And I caught it about five minutes before I boarded my flight.  With no opportunity to take any medicine, nor procure any tissues (I would speak the word Kleenexes here but it feels funny writing it), this was not a fun experience.

I survived, however, and a few days upon returning to San Francisco returned to see Nicole for my next PT checkup:

“How are things going?”

“Eh, about the same.”

“Any new issues?”

“Nope.”

Sheepishly, I denied any outlawed running, and I think she believed me (it’s possible she saw right through me, she’s sneaky).  After all, my knee did feel fine the day after I iced it in Germany, and things were still pretty much normal now that I was back in SF.  One more PT visit down, things with my knee seemed to be progressing as they should, life was good.

Training log for May

Two more weeks went by, weeks in which I obeyed the no-running rule (you can view May’s training log overview to the right).  I also wasn’t doing my PT exercises as frequently as I probably should have but I was making noticeable positive progress each day so my incentive to do so was definitely diminished.

At this point I should break the chronological timeline and go back to the middle of March of this year.  My great friend Rob lives just outside of NYC and approached me with the idea of participating in the New York Ragnar Relay, a 182-mile relay race that starts upstate in the Catskills and roughly follows the Hudson River south before finishing in the Bronx’s Van Cortlandt Park, where I ran a few times during my very brief collegiate running career.

Having just come off a rough week, I was eager for the adventure and said I was in.  I bought my plane ticket, and added New York and the race date, May 15-16, to my very busy spring travel calendar.

Scene along the Ragnar Relay course in upstate New York

Fast forward now back to May.  Despite my knee injury I was determined to run the relay – I had been looking forward to it for a long time, and besides, I knew it would be a ton of fun.  I never told Nicole it was on the horizon but it was there, in the back of my mind, an indelible date on my training and recovery calendar that Nicole, naturally, had no idea existed.

And my PT visits in the beginning of May proved promising.  In fact, the timing seemed to be working out perfectly: the Monday before the Ragnar Relays Nicole said I could start running.  The beginning of that week I was in LA for a conference for work, and I ventured out of my hotel the first evening for a 1-mile run.  A half mile out, a half mile back, and a grin from ear to ear: everything felt fine.

The next day, I added an extra half mile to the total, taking in a little bit more of the Simi Valley scenery.   And the next day, a whopping 2 miles.  No knee issues, and I was floating on air.  I caught the evening flight out of Burbank Airport back to San Francisco, switched terminals at SFO and hung out there for about an hour, then caught the red eye for Newark, the omnipresent plane noise accompanied by thoughts of the pending running adventure.

There are many Ragnar Relay events held across the country in places diverse as New England, Florida, Washington state, southern California, Arizona, Utah, Wisconsin and Minnesota.  The premise of each is the same: 12 team members run approximately 180 miles starting sometime on the morning of the first day, and finish approximately 24 hours later.  The teams split up into two vans of six people each, and while one van’s six runners are racing, the other six can drive ahead, and rest for their upcoming legs (this becomes especially important during the overnight legs).   The race is divided into 36 legs, three for each runner.  No two legs are the same.  Some are mountainous or hilly, some flat.  Some are more than eight miles, some less than three.  Some run during the day, and some occur at 3 in the morning.  The only consistency in the whole plan is that all 11 runners on your team need to run before you can run your next leg; hence if you start with leg 2, that means you also run leg 14 and leg 26.

The New York Ragnar Relay course: 182 miles from Kingston to NYC. My legs were nos. 8, 20, and 32.

My team consisted primarily of Rob’s co-workers and their acquaintances, most of whom were recreational runners.  I wouldn’t consider myself a professional runner per se, but I was a former high school and collegiate athlete, a former coach and a member of an ultrarunning club so by comparison I was among the team’s die-hards and earned the privilege of running the longest and most difficult legs of the 182-mile jaunt from Kingston to New York.

In April, before my injury, I was thrilled about my assignment.  After the injury, you can imagine I was a bit nervous.

But I wouldn’t know what was in store for me until that fateful day in May arrived.

This is the fourth article in a series describing my first ever running injury in 20 years, how I’ve dealt with it heretofore, and my path to recovery.

In my last injury post I detailed what happened to my knee, why it happened, and my physical therapist’s prescription for recovery.  Now I’ll share the beginning of my meandering (and still not fully traveled) road to recovery.

As I mentioned in my previous post, following through on the prescription of therapeutic exercises wasn’t as easy as listening to it, and then telling my PT Nicole that I would do what she was telling me I should do.  Prior to my injury I would run 30 miles in a heartbeat but you would have had to beat me just to get me to do 30 pushups.  If physical activity didn’t involve running, or any of a number of team sports like baseball or basketball, I wasn’t interested.

So the directive to perform a number of exercises each night involving odd body movements targeting muscles in areas I never knew I had them was not necessarily met with loads of enthusiasm on my part.  My first few visits to see Nicole I would dutifully report that I had performed all of my exercises in the intervening days when that was really only a half-truth, if not a quarter-truth.  The truth was that I hated doing anything that didn’t involve running.  And I’m sure Nicole knew.  But like she always tells me, “this is why I learned just as much about psychology in PT school as I did about physiology!”

The streets of Grossostheim

Nevertheless, my initial diagnosis was a moderate tear of my MCL, something from which it should only have taken me about four weeks to recover (with “should” being the operative word here).  The fact was, however, that I had a work trip to Europe planned to London, Paris, Frankfurt, Cologne, and Munich at the end of April and on the weekend I was going to be in Frankfurt I was planning to run the Marktplatzlauf (rough translation: Marketplace Run) 10K in Groβostheim, a little town not far from my company’s offices outside Frankfurt.  And no little MCL tear was going to keep me from running my first road race in Europe.

My friend Brandon had just moved to Frankfurt to spend in a year in our office there and along with one of our German coworkers we jumped on the Autobahn and headed out to Groβostheim for the race.  The town was quaint, everything you might expect from a western European countryside town, with its church steeple anchoring the central town square, and cobblestone streets that seemed to meander in every direction with no particular rhyme or reason.  It was a unique feeling: the juxtaposition of this historic town, a scene with which I was not at all familiar, and that of a typical road race, something that’s as familiar to me as apple pie.

I studied German for a year in high school and two years in college and like to think I can speak it with some level of conversational competency.  (For some reason, my German always seems to improve with a drink or two).  And after spending four days in France, an incredibly beautiful country but one whose language I am terrible at even attempting to speak, I was excited to have the chance to flex my German pipes (yeah, E-Trade commercial) in the land of native Deutsch speakers.

It was a little bit more difficult than I imagined, as native speakers naturally speak very quickly.  And with my limited vocabulary, I found myself ensuring I only spoke to people in German when I knew their answer would consist of words I would understand, such as “Where is X?” or “What time is it?” or “How much is that?” (I know, I must have been a thrilling conversationalist).  I didn’t know too many German words related to running other than laufen (to run), schneller (faster), langsamer (slower), or die Schuhe (shoes), so I pretty much kept to myself on the starting line.

The gun went off and my knee felt great.  As we turned one sharp corner after another I kept avoiding the cobblestones as much as possible to prevent any cobblestone-induced injuries.  Aerobically, it had only been about three weeks since I had last been regularly running so I was able to stay near the front of the pack for awhile.  I followed the leaders through the town scenes of what I imagined could have been a World War II-themed video game (except without all the blood and destruction).

My race bib

The course consisted of four 2.5K laps around the same loop, with each lap crossing through the Marktplatz twice.  After lap one I was beginning to notice a slight tingling in my knee.  After two laps I knew I had issues.  I was planning to peel off the course and finish with the 5K runners, who of course only needed to do two laps, not four.  No sooner was I veering toward the finish chute, however, when a nice little German lady noticed that my racing bib was color-coded for the 10K race and shooed me back down the street.  And, in my state of concern for my knee, I couldn’t at that moment quite come up with the words “My knee hurts, I have to stop.”

So I did one more half lap, where I conveniently blended off the side of the course into the middle of the crowd in the Marktplatz.  My knee was not happy with me.

Damn.

I was a little bit worried.  I arrived back at Brandon’s place in Frankfurt that evening and promptly iced my knee (icing: another activity I was never very fond of until this injury).  We then went out that evening to the Nacht der Museen (Night of the Museums), where all of the many museums (film and TV, natural history, aerospace, and so on) along the Main River in Frankfurt are open during the nighttime and have bands and open bars.  I definitely recommend it if you’re in Frankfurt at the end of April.

I woke up the next morning, and my knee, surprisingly, felt okay.  But I made no plans to run on it, and would not do so again for, oh, another two weeks or so…

The Marktplatz: Race start and finish

This is the third article in a series describing my first ever running injury in 20 years, how I’ve dealt with it heretofore, and my path to recovery.

My first few trips to see my physical therapist Nicole were a treat for my inquiring mind.  The human body is an amazing machine.  In fact, it is miraculous. In my first few visits I learned more from Nicole about biomechanics than I had in my entire life up to that point.  The fact that the solution to my knee and hamstring problem lay somewhere between my hips and my rear end was illuminating, to say the least.

Nicole earned a clinical doctorate in physical therapy from USC and has done extensive post-graduate research on knee issues just like mine.  So needless to say I was delighted when I discovered that my exact problem was something she’s been extensively studying for the last several years.

Here’s how she laid it out for me: for a long time (almost 20 years, in fact), because of my natural running form, I was able to stay injury-free save for the occasional ache, pain, or shin splint.  That changed on April 4 when I went on the run I described in the Marin Headlands.  Specifically, toward the end of the run, I ran an extremely steep downhill grade into a strikingly beautiful coastal area of the Headlands known as Pirate’s Cove.  I was at the edge of losing control, and each footfall was high impact.  This lasted for somewhere between 300 and 400 yards.

I had weak hip stabilizer muscles because, well, I hadn’t even known what hip stabilizer muscles were, much less devised a strategy for strengthening them.  The hip stabilizers, through the miraculous web of fiber, tendons, bone and muscle between them and the knee, actually help, when strong, to stabilize your knees and prevent them from buckling inwards.  Under normal circumstances, I likely would have been okay, but if you combine the steep terrain, the lack of control while running down it, and the fact that I was no longer 18 years old, what I had was the perfect recipe for an MCL (medial collateral ligament) tear.

The window into the weakness of my hip stabilizers opened up an entirely new interest for me in core strength in general, in which the hip stabilizers only play a part.  In fact, when I started running with the Endurables in September of ’08, each of our Wednesday workouts was done on the track but labeled as a “Core” workout because between each trip around the large polo fields at Golden Gate Park Rachel would have us doing any number of pain-inducing drills that worked on our cores.  At the time I didn’t investigate too closely as to exactly why our core strength was important, I just took her word for it .

Core strength is about overall fitness and ensuring that each part of your body is strong, but also, more importantly, it is about stabilizing the body under athletic stress. For me and my fellow Endurables runners, this was of utmost importance given that most of us were training for distances of either 50K (that’s 31 miles) or 50 miles. When your body is under that much stress, especially on the hilly and mountainous terrain here in the Bay Area and especially as you age, you need to eliminate as many potential causes of injury as possible.

So after my injury, Nicole prescribed a series of exercises that worked on my core and specifically targeted my hip stabilizers.  I became very familiar with what Nicole calls “clams,” otherwise known scientifically as a “Lying Hip Abduction” (insert all jokes about the kidnapping of less-than-truthful hips here, please). Clams look exactly like the mollusk they’re named after – you lay on your side with your knees bent, and rotate your knee up and down until it hurts so much in your butt you can’t do it anymore.  (Trust me, with a lot of these core exercises, you find out you have muscles in places you never knew you had them.)  Active.com has a great article on core strength with a 9-week core conditioning program that I recommend checking out.

So as a physical therapy patient, now I knew what had happened to me, and why it happened.  Following the prescription, however, which entailed a prohibition on running of any form and diligent performance of a whole new slew of exercises was another story.  I didn’t run at all for many days, until I did.   And historically, I’ve always been a one-track mind when it comes to exercise: running.  That means, I would run, and often times run a lot, but rarely stepped foot in a weight room, or did exercises that didn’t involve quickly putting one foot in front of the other.

These were lessons yet to be learned, and that saga would play out over the months of April and May.

Image by eOrthopod.  Photo by Ollie Crafoord.

Yesterday I received a letter from my health insurance company informing me that after 20 visits to my physical therapist, no, they weren’t going to cover any more.  As to whether this prohibition applies to this year or forever, I’m not quite sure yet.  But it has me anxious.

In Monday’s post, The Anatomy of Injury Denial, I began detailing my 2009 personal fitness journey.  Today I’d like to pick up where I left off.

For two days after the long Saturday run in the Headlands, I ran at my gym on the treadmill, and made the following entries in my training log:

Monday, April 6, 2009
Distance: 3 miles
Notes: slight tenderness in right side of left knee/Achilles tendon/shin

Tuesday, April 7, 2009
Distance: 4 miles
Notes: [knee] tendon was really weird today – hurt at first when running quickly, did some biking, some pushups, came back, didn’t feel quite normal but could still run 7.5 [treadmill pace] comfortably – odd.  hopefully goes away tomorrow

Well, it didn’t go away.  In fact, the next day was our Endurables weekly workout (then hosted by Rachel Rodriguez, proprietor of Aim Fitness, who by the way kicks butt).  Rachel is an excellent evaluator of running form, and after I made several pained attempts to circle the track around the polo fields at Golden Gate Park, she took a closer look at my left knee.  “Something not right is going on there,” she said, and suggested I get in touch with Nicole Haas.

Nicole is a physical therapist with San Francisco Sport and Spine Physical Therapy, whose clinic is housed inside Aim Fitness, Rachel’s gym.  We’ve gotten to know each other pretty well over the past eight months, but before I saw her in April, I had never seen a physical therapist in my life.  The worst pain I had ever suffered as a runner was a solid case of runner’s knee as a freshman in high school that I outgrew within a few weeks.

Nicole’s diagnosis: I tore the tendons on the inside of my knee because my hips were weak.

What?

After a few more visits and an injection of patience on my part, this would all start making sense.

April after the injury: April 4

As a high school cross country and track coach, I witnessed more than a few times the sight of an athlete understating the severity of an injury to avoid being sidelined.  Instinctively, I understood this as a natural reaction to an unfortunate situation, especially for the most competitive boys and girls.  But it never really made sense to me.  I thought, you’re only delaying the inevitable – and in all likelihood making it worse. And I would relay that thought to them quite frequently.

Well, having not walked that particular mile in their shoes yet, it was easy for me to spout my wisdom.  Living by it, however, when I encountered the situation myself, was another story.

Like I mentioned in yesterday’s first post, I began 2009 with a mission to get in the shape I was in when I ran my PR (personal record) in the 5K: 15:59 (for those calculating, that’s 5 minutes and 9 seconds per mile).  I was 18 then, and I’m 30 now, but I know that it’s possible and that is still my goal.

January and February sauntered past with nary a step in my running shoes having been logged, but by March I was on my mission in earnest.  In fact, below is a visual representation of almost every training activity I’ve logged this year.  I’ll go over this in more detail in future posts, but orange corresponds to a day that I ran, and gray corresponds to a day that I did some other physical activity, most often lifting weights.  Orange and gray days mean I did both.

On April 4, I went on a great 9-mile run with my trail running club, The Endurables, whose exploits you can also track over at the Trail Run Times.  It was a challenging loop through the Marin Headlands, but I was hanging with the lead pack pretty much the entire way.

I arrived back at Muir Beach, our start/finish point, feeling on top of the world.  I had been running consistently for only one month yet I was already feeling in fantastic shape.  I couldn’t wait for the next Wednesday when we would meet again for our weekly track workout in Golden Gate Park.

I took that Sunday off but was back at it on Monday on the treadmill at 24 Hour Fitness (yes, I fell victim to their well-placed Biggest Loser marketing) in Larkspur.  Something didn’t feel right.  My left knee felt like it wanted to collapse inward.

But it didn’t seem that serious, so I thought, why worry? Well, in a few more days, I’d have my answer to that question.